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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): <br /> Address for Vehicle: ��/`� = S'� ✓V1 �,_O.n S Zc—G/ <br /> sEPe�YAPC1resr - <br /> 1) License Plate#: 44) Year: <br /> 2) Vehicle Vin#: 1 {� a()'1'b_ (Co 5)'We/Model: lL <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of caner: (p <br /> eatAdcrress 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 /> o ce It in revocation and penalties. <br /> �hlh1 <br /> nature of Icle O erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: `? &4c5 z-/ <br /> treat Address 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 /> Liquid&solid waste disposal wtensil washing sink <br /> (2 or 7 compartments) ❑Store frozen food ehicle wash facilities <br /> ❑ Preparation of food 14wot&cold water for cleaning 544ailim&hand washing ❑ Store refrigerated food <br /> 6ne;ofoCommissary <br /> fo supplies Ptnvide potable water �Ovemight parking �dequate electrical outlets <br /> Owner/Opera tor Date <br /> - - - - <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 REHS Date <br /> EHD 16-017 sets MFPU APPLICATION <br /> 7/18/2008 <br />