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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> r <br /> VEHICLE INFORMATION, <br /> Vehicle Name (DBA): <br /> Address for Vehicle: 7 3 U <br /> Street Address City <br /> 1) License Plate#: 1V / o� �1 9 4) Year: U O S <br /> 2) Vehicle Vin#: Make/Model: <br /> 3) State Decal #: 6) Color: <br /> 710 RITZZ <br /> Name: <br /> Address of Owner: 113 <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 pe it holder must notify this office to make the necessary changes. Failure to notify this <br /> office ay result in p mit rev cationupenalties. <br /> Si ture of Vehicle O erat r Date <br /> C MISSARY INFORMAT N <br /> Business Name: Gf <br /> Owner Name: U <br /> Site Address: <br /> Street ress city <br /> Phone: ( <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 /> tensil washing sink ❑ Store frozen food ehicle wash facilities <br /> Liquid&solid waste disposal (y or 3 compartments) <br /> reparation of food �&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> St e dry food/supplies rovide potable water vernight parking dequate electrical outlets <br /> Si nature of CommissaryOwner/O erator Date T <br /> r turf i ui, 44•:! <br /> HEAL:TI-I 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 REHS Date <br /> 5 of 6 MFPU APPLICATION <br /> EHD 16-017 <br /> 711 8/2008 <br />