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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): 116AZ ����-'� ;;� p <br /> Address for Vehicle: to? �5`�fe-(�, CVi 95cZ�,5 <br /> Street Address City <br /> 1) License Plate#: KK-5 9 4) Year: t <br /> 2) Vehicle Vin #: 5) Make/Model: 5 FSC/LI <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: r1? j1V4 k19)1214"62 <br /> Address of Owner: L' <br /> �5 5 G: 4 RDI JC. 4j 5 i i <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 may result in permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: - `��)(I (D -U lip <br /> Site Address: / 7 S t- 6U !©Gr1 ,S (CI GkT6lL) <br /> Street 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 L"f utensil washing sink <br /> (2 or 3 compartmen's) —E�Store frozen food Vehicle wash facilities <br /> Preparation of food �ot&cold water for cleaning Q Toilet&hand washing UJ/S6e refrigerated food <br /> IR-Store dry food/supplies 2Provide potable water Overnight parking E3Adequate electrical outlets <br /> Signature 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 MFPU APPLICATION <br />