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{ <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFO- .RMATION. : <br /> Vehicle Name (DBA): 05 cco <br /> Address for Vehicle: 4(3 %'V <br /> Street Address r' City <br /> 1) License Plate#: �1DjI RR5 4) Year: 200 3 <br /> 2) Vehicle Vin #: L—CA o50 giAjW75,3 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: Q.' <br /> Address of Ov✓n r: <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 /> g4bto G 11 1221 12, <br /> S&ure of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 1 <br /> Owner Name: <br /> Site Address: <br /> Street Address Cit <br /> Phone: ()M) dSC) <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 fJ Utensil washing sink <br /> (2 or 3 compartments) ,Store frozen food ElVehicle wash facilities <br /> Preparation of food QHot&cold water for cleaning K]Toilet&hand washing �fr Store refrigerated food <br /> ❑ Store dry food/supplies Provide potable water Overnight parking ,KAdequate electrical outlets <br /> l <br /> Signature of Commissary 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 /> 7/18/2008 <br />