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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): <br /> Address for Vehicle: 1-012, <br /> Str et ddress city <br /> 1) License Plate#: 21(J J 4) Year: <br /> 2) Vehicle Vin #: f 7—�l QJEC.5) Make/Model: <br /> 3) State Decal #: 9 6) Color: <br /> VEHICLE OWNER.INFORMATION, <br /> Name: C U <br /> Address of Owner: -'- '5�e <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 /> e 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 /> ?) /ss <br /> Si nature of Vehicle Operator Date <br /> -Cb IIR^.!SSP,.RYtINF..ORMATION _ <br /> Business Name: rj ve ^ P , /S BL <br /> Owner Name: Grp USG .J <br /> Site Address: 1 <br /> Street Address city <br /> Phone: (�20 .S 7G/ O <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 0 compartments) ❑ Store frozen food ❑ Vehicle wash facilities <br /> Preparation of food ❑ Hot&cold water for cleaning ❑Toilet&hand washing ❑ Store refrigerated food <br /> Store dry food/supplies ❑ Provide potable water ❑ Overnight parking p❑Adequate electrical outlets <br /> /O <br /> S_i nature o ommissa caner/O erator Date <br /> AL-TH 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 01`6 MFPU APPLICATION <br /> 7/18/2008 <br />