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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application :may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): Lr ;� <br /> Address for Vehicle: 7 <br /> Street Address City <br /> 1) License Plate ; 4) Year: /jC <br /> 2) Vehicle Vin #: C Make/Model: <br /> 3) State Decal*: 6) Color: GG/ <br /> VEHICLE OWNER INFOt NIAnTION <br /> Name: SO <br /> Address of Owner: <br /> Street Address Citi, <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 11429-:1 & 1142-79-7). if the use of the cor nnissa.-y is <br /> disc tinuedithe permit holder must notify this office to make the necessary changes. Failure to notify this <br /> off"ce`mav`i It in mit revocation and penalties. <br /> gig e of Vehicle Operator Date <br /> COFtRKCSSARY INFORFVIATIO J <br /> Business Name: ��. Z �Cc i e <br /> Owner IN'arne: <br /> Site Address: C <br /> Street Address City <br /> Phone: !� �1 <br /> , <br /> f, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> 0-6quid&solid waste disposal [9 utensil washing sink ❑ Store frozen food Z-'defile wash facilities <br /> (2 or 3 compartments) <br /> /— - _---- <br /> 'Preparation <br /> 'Preparation of food ®- off t&cold water for cleaning E-Glet&hand washing ❑ Store retrigerated food <br /> i <br /> to ryfood/supplies ® vide potable water Overnight parking Adequate electrical outlets <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT ` <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County RI=FiS Date <br /> EHD i6^617 5 of 6 TOFPU APPLICATION <br />