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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): %1,e <br /> Address for Vehicle: /pt' �i7lawls �• e�w. v <br /> Street Address city <br /> 1) License Plate#: (r �{ �j'((p 4) Year: l.5 Ci <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal* 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: ob•o�+— {{=vet S <br /> Address of Owner: �o l Svi n,36 a Lv 5uL/{zJ <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 r permit vocation and penalties. <br /> Si ature of V cle Operator Da <br /> COMMISSARY INFORMATION <br /> Business Name: c-+ <br /> Owner Name: ne c-c <br /> Site Address: <br /> Street Address City <br /> Phone: (9/(/) '5/ el 7 2T 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 /> Liquid&solid waste disposal I—"-tensil washing sink tore frozen food QVe—hicle wash facilities <br /> 11,,r (2 or 3 compartments) <br /> U Treparation of food of&cold water for cleaning Q'I oilet&hand washing Store refrigerated food <br /> -9tore dry food/supplies rovide potable water -- - Ovemight parking dequate electrical outlets - <br /> Si nature f 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 />