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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): # 111A <br /> Address for Vehicle: 0 _ b'1 ✓VI 1. p (�S3 <br /> 5 <br /> 5+/ <br /> Si5b <br /> raWl <br /> 1) License Plate#: !g ' V 44) Year: orilQ q <br /> 2) Vehicle Vin#: 1)7-L) J 71D 5)'-%e/Model: rt <br /> 3) State Decal #: 6) Color: <br /> VEHICLE-QWNER INFO_RMATIO_N <br /> Name: <br /> Address of wner: Q (� <br /> reef ress 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 /> c7e It�ermi revocation and penalties. <br /> o <br /> nature of Icle O erator Date <br /> .COMMISSARY- INFORMATION <br /> Business Name: <br /> Owner Name: AA <br /> Site Address: 5 L� <br /> treet Address city <br /> Phone: ( ' <br /> 1, 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 f 9utensil washing sink ❑ Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food C>guot&cold water for cleaning 54vflet&hand washing ❑ Store refrigerated food <br /> ❑ Store dry foo supplies vide potable water �Ovemight parking Adequate electrical outlets <br /> Sin a of Commissa 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 REHS Date <br /> EHD 16-017 5 of 6 WPU APPLICATION <br /> 7/18/2008 <br />