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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> t -T Qyi 1' <br /> Vehicle Name (DBA): <br /> Address for Vehicle: 0-0 'Vo <br /> Street Address city <br /> -2 <br /> 1) License Plate#: 4) Year: 0 0/(o <br /> 2) Vehic]eVin #: tiwcu�ilgc�) C71001"" Make/Model: <br /> 3) State Decal #: 6) Color: <br /> ,;,v <br /> Name: 00 <br /> Address of Owner: [00,� LOK,, '1,)&,K Pldj� 1* 7 SO 60R,04 q5639- <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 Orerator Date <br /> COMMISSARYi'INFORMATION <br /> Business Name: <br /> Owner Name: y?) <br /> Site Address: (-", Zo i; : f- 15 7t-16 Z= 121W %er <br /> reeNddress city <br /> Phone: (76-e) ) 5"7 <br /> 1, the commissary owner, can and will provide the necessary facilities'for the above mentioned vehicle at my <br /> commissary as checked below: <br /> [2/Liquid&solid waste disposal ❑ Utensil washing sink 11 Store frozen food El Vehicle wash facilities <br /> (2 or 3 compartments) <br /> FlPreparation of food �Hot&cold water for cleaning [:] Toilet&hand washing El Store refrigerated food <br /> tore dry food/supplies ElProvide potable water U,6�vernight parking E]Adequate electrical outlets <br /> Si nature of Commissary Owner/Operator Date <br /> E <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 /> 7118/2008 <br />