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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION°r <br /> Vehicle Name(DBA): ffekAd <br /> Address for Vehicle: N&A — S <br /> strestaddrerss cqy /_ <br /> 1) License Plate#: ldrYu1 37 4) Year: �D�(w, �1 <br /> 2) Vehicle Vin#: j-2A4fS05/falloT76 5) Make/Model: <br /> 3) StateDecal* 6) Color. <br /> VEHICLE OWNER_INFORNIATION: <br /> Name: AAC <br /> Address of Owner. 3oZ/7 qJ�! <br /> street Addrass city <br /> The mobile food fecility shall operate out of a commtseary and shall report to the commissary at least oncti,each <br /> operating day for cleaning and servicing (CalCode sections 114295 8114297). 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 r suit n permit r tion and penalties. <br /> i nature of Vehicle Obera& Date <br /> COMMISSARY INFORMATION ) ` <br /> Business Name: <br /> Owner Name: <br /> Site Address: 7-q 0C) C. ) <br /> Streetaddress 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 /> A Liquid&solid waste disposal Utensil washing sinkr Q Store frozen food Vehide wash facilities <br /> (2 w3 C0MN1t mMs) <br /> ❑Preparation of food Hot&cold water for cleaning ®Toilet a hand washingIQ Store refrigerated food <br /> 1 <br /> ❑ Lfbodisuppil ®Provide potable water Overnight parking Adequate electrical outlets <br /> Si nature of ComAissary Owne erat 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 15.017 5 orb MFPU APPLICATION <br /> Tlt5r2555 "` <br />