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VERIFIS TION OF VEHICLE C MISSARY <br /> Please provide all_JWmation requested. An incomplete ap�ion may delay approval <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: /- CAoZ <br /> Street Address city <br /> 1) License Plate#: �I�M���y 4) Year: <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: Z <br /> Address of Owner: ,,-) S <br /> Street Address I city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once <br /> each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the <br /> commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure <br /> to not tb' dffi ay result in permit revocation and penalties. <br /> Sin ire of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ( Y'y//" W7 say( <br /> Owner Name: U/ -�ry <br /> Site Address: 097` /b (E!� <br /> Street Address - city <br /> Phon )-'/,Kg L ZO <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 /> Liqu' &solid waste disposal Utensil washing sink ❑Zile <br /> ozen food ❑Vehicle wash facilities <br /> (3 mpartment slnk) <br /> Preparation of food Hot cold water for cleaning hand washing ❑ Slor efrigerated food <br /> e ry food/supplies Provide potable water Overnight parking Adequate electrical outlets <br /> I n tur of Onmissa Owner/O erator 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 SQL(P&VVI-P V�'kn <br /> County. j� <br /> 6' AL )AA� <br /> Signature of County IRRbt Date <br /> EHD 16-013 Page 8 of 9 MFF APPLICATION <br /> 7/28/2010 <br />