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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): C_( ))u g Gjn� S i �r <br /> Address for Vehicle: L,Lp <br /> Street Address city <br /> 1) License Plate#: W $ S ( I 0 4) Year: �'? of �� <br /> 2) Vehicle Vin#: S 5) Make/Model: "T'ro.t ks- 1 <br /> 3) State Decal #: 3 O Ll'Ke� y Color: �j 6-cok <br /> VEHICLE OWNERINFORMATION <br /> Name: ac>C p r <br /> Address of Owner: ca 43 ( t Thos n <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 /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION ' <br /> Business Name: 'p <br /> OwnerName: t OQ <br /> Site Address: ZC) S• SCj,C - ec\kzb c & Civ <br /> Street Address city <br /> Phone: (2(ri ) 12—Co S aC (204) (0(o 3-S7B I G- <br /> 1, <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 Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <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 ®Adequate electrical outlets <br /> Signa ure 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 />