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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 Nam (D S <br /> Address for Vehicle: l/ ah-0 9Sd� <br /> Street Address cit/ y <br /> 1) License Plate#: j qg 74) Year: <br /> 2) VehicleVin* Make/Model: <br /> 3) State Decal#: �� 6) Color: <br /> VEHICLE.OW ER INFORMATION. <br /> Name: <br /> Address of Owner: ' <br /> Street Address C(tY <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 /> SfmO�1 &t2N e ec, i <br /> Signature of Vehi&le Operator Date <br /> COMMISSARY,I_NFORMATIO <br /> Business Name: ` <br /> Owner Name: / <br /> Site Address: <br /> Street Address / cify <br /> Phone: — D <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 Utensil washing sink ❑ Store frozen food ® Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑ or dry food/supplies Provide potables water Dy Overnight parking Adequate electrical outlets <br /> 7 <br /> Signature of Commissary Owner/O or 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 /> 7/18/2008 <br />