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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): (✓(�)�S � Gjn� 5 iklt�r <br /> Address for Vehicle: (o za 554 Lfl <br /> Street Address city <br /> 1) License Plate#: W 2 5 fel p 4) Year: C) <br /> 2) Vehicle Vin#: �T 5) Make/Model: 'Tyo,t kz'r <br /> 3) State Decal #: '3 O Lj'K� �� Color: 42� track <br /> VEHICLE.OnWNER INFORMATION <br /> Name: "O C r <br /> Address of Owner: Q 43 l t av C--, Thorn <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: <br /> Owner Name: <br /> Site Address: Z0 S• C'C eta cE& Lek <br /> Street Address City <br /> Phone: (ZC9 �V2—CP?S coto3— 1 S <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 TFJ Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food .Hot&cold water for deaning Toilet&hand washing ® Store refrigerated food <br /> Store dry food/supplies ® Provide potable water Cs.overnight parking ®Adequate electrical outlets <br /> SI na 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 16-017 506 MFPU APPLICATION <br /> 7118/2008 <br />