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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incompleteapplication may delay approval. <br /> WEHICLE INFORMAtTION.u3+`N W, -310in . <br /> Vehicle Name (DBA): i Li OJS S <br /> Address for Vehicle: 02 <br /> Street Address City �7 <br /> 1) License Plate#: 7/33 �3 4) Year: <br /> 2) Vehicle Vin#: C��S23,?62,L 5) Make,Model: <br /> 3) State Decal#: 6) Color: <br /> ?SV, x � f � <br /> EWe"eS r�r,'c'Tm 's-'yt a'°S" � '•i <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 in permit vocation and penalties. <br /> Signature of Vehicle Operator Date <br /> -got YrT� �- �� 1 IVINIISSARY�_IN�F,ORIVIAI ON"rE '!��;�,:>u��a�"'a,.��c�a,.f=°�t�. �•7�� ..:,�F:`"`s <br /> Business Name: ' <br /> Owner Name: , <br /> it <br /> Site Address: yogufs Qrj' <br /> Stree city <br /> 1, <br /> Phone: &?) 1p s 7� <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 /> XUquid&solid waste disposal Utensil washing sink ❑ Store frozen food Nr Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of foodr�Cqq Hot&cold water for cleaning a Toilet&hand washing ❑ Store refrigerated food <br /> ❑ ore ry foo d/suppli nlJ Provide potabl water ®Overnight parking RrAdequate electrical outlets <br /> 7- g -/e <br /> SI nature of COT issary OwnegiVeratok Date <br /> -r•- uer r a�,tz � rr— 'i ni 2 1 ye S1. <br /> f r R a �t n nial <CI➢ .{pol'1g <br /> �HEALT,H�DEF'AR•l'MENT "4+ � c 1���_� 'y �t 5 n�� �. i MiwL�u'��i�ry� § e,� ;,) + '�. � r 1 I�+ n Y^Ss r tli°-r, <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 16-017 506 MFPU APPLICATION <br /> 7/18/2008 <br />