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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): oJs S <br /> Address for Vehicle: A/ ` <br /> Street Address city �7 <br /> 1) License Plate #: 'M193 eJ4) Year: <br /> 2) Vehicle Vin#: e P/L1 3S23,?4" 5) Make/Model: ,! <br /> 3) State Decal#: 6) Color: <br /> - <br /> WEHICL'E O.WNER'INFORMATION <br /> Name: <br /> Address of Owner: <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 inpermit vocation and penalties. <br /> 7���if�� <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY;INFORMA ON <br /> Business Name: r <br /> Owner Name: i1 <br /> r <br /> Site Address: s D5 <br /> Stree Address city <br /> Phone: j ) <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 <br /> (2 or 3 compartments) ❑ Store frozen food Xr Vehicle wash facilities <br /> ❑ Preparation of food .® Hot&cold water for cleaning .�J Toilet&hand washing ❑ Store refrigerated food <br /> ror'edry food/ tablp water 4KI Overnight parking Adequate electrical outlets <br /> Signature of Co issa Owne erato Date <br /> -. . <br /> tHEALTH 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 />