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RECEIVED <br /> VERIFICATION OF VEHICLE COMMISSARY pA�P,R 2 7 2017 <br /> Please provide all information requested. An incomplete application may delay appro R01MENrALN�.8 <br /> MlrlSE S <br /> GVEkIICLE'IN.ORNIATION„_ r <br /> Vehicle Name (DBA): <br /> Address for Vehicle: S C <br /> Street Ad ress city <br /> 1) License Plate#: pU Lel a 4) Year: "kni l <br /> 2) Vehicle Vin #: CPai i T S_ �5 5) Make/Model: yc,c—� act <br /> 3) State Decal #: 6) Color: <br /> VEHICLE QWNER,INFORN1ATIgN, <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 ermit revocation and penalties. <br /> n ehicle Operator Dafe <br /> Busines ame: � oyt <br /> Owner Name: <br /> Site Address:?bg5- Pio oa'tCo <br /> Street Address city <br /> Phone: (201 ) 957- - 100 P <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 /> dLiquid&solid waste disposal I—I Utensil washing sink <br /> (2 ora compartments) Store frozen food Vehicle wash facilities , <br /> ❑ Preparation of food [� Hot&cold water for cleaning dToilet&hand washing [Store refrigerated food <br /> [�ZZ; <br /> [`�Provide potable water ❑ Overnight parking Adequate electrical outlets <br /> �na re of mmissa Owner/Operator d6te <br /> [HEALTHiDEPARTMENT r 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 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />