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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE'1 NFORMATIO,N, <br /> Vehicle Name (DBA): <br /> Address for Vehicle: im S (A Wft IfW�Tgn CIA 15203 <br /> Street Address city <br /> 1) License Plate#r: �,nRAH M 4) Year: Q <br /> 2) Vehicle Vin#: VPI`I�l mo (V m-1 5) Make/Model: <br /> 3) State Decal#: �� ���� 6) Color: nQ/ <br /> VEHICLE1.0, NER,I,NFORMATIQN <br /> Name: RIM WKICIA hf0frA <br /> Address of Owner: 11� 5j n <br /> Street Address City <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 114295 & 114297). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office. ,.res hermit revocation and penalties. <br /> Signature of Vehicle Operator Dat- <br /> COMMISSARY INFORMATION: <br /> Business Name: W <br /> Owner Name: <br /> Site Address: W l B OV r 0 G ' `l) <br /> Street Address city <br /> Phone: (20q) I - 1941 <br /> I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> Liquid&solid waste disposal Utensil washing sink ❑(2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> reparation of food of&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> tore dry foo liesIctable water vernight parking Adequate electrical outlets <br /> nature of is r Date <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 REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 Aftft- <br />