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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> 11111111 1 NIMBI 11 <br /> ail <br /> Vehicle Name (DBA): A- � Ti@ © o <br /> Address for Vehicle: 3 L <br /> Street Address - city <br /> 1) License Plate#: ,2' 1"'per�� 4) Year: <br /> 2) Vehicle Vin #: s$—Sj' Make/Model: <br /> 3) State Decal #: 6) Color: (f, <br /> L 3 <br /> Name: <br /> Address of Owner: f{ c 333 <br /> StreetAddrei 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 icing,(CalCode sections 114295 & 114297).-If the use of the commissary is <br /> discontinued, the p h must-fiotify this office to make the necessary changes. Failure to notify this <br /> office may resul ' pe ' r o and penalties. <br /> 2.5 <br /> Signature of V Cr Dat <br /> 11111iii S! Iii, I <br /> lip, Iiiiiii <br /> Business Name: <br /> If <br /> Owner Name: e �l <br /> Site Address: c C <br /> Street Address city <br /> Phone: ) [ <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 /> z or 0 compartments) <br /> ❑Preparation of food Hot&cold water for cleaning Toilet&hand wa6i ling ❑ Store refrigerated food <br /> ❑Store dry foodisupplies ., Provide potable water [�-Ovemight parking Adequate electrical outlets <br /> Signature of Com missa erator Date <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 /> l 16-017 5 of 6 MFPU APPLICATION <br /> 7/16/2006 _ <br /> 'L. <br />