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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): ° <br /> Address for Vehicle: VY ' � ft- U 1 C <br /> Street ddress City -- <br /> 1) License Plate#: 4) Year: �ql <br /> 2) Vehicle Vin 5) Make/Model _ <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION' �dU. <br /> ta .__ 3Ns �" fi,`Czasbia <br /> Name: �( Z <br /> Address of Owner: <br /> Street Addr s 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 <br /> permit revocation and penalties. <br /> 1218 � 010 <br /> Si nature o ehicle Operator Date <br /> COMMISSARY INFORMATION a <br /> v�tv. .sm �.,l;1lY d",t �m�Y!F /MM,-1 .f.Uf'3fiu€nkFM y' <br /> Business Name: 1 <br /> Owner Name: f <br /> Site Address: <br /> street address 'S+ Lgr <br /> city <br /> Phone: -7 e <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 /> Liquid&solid waste disposal Utensil washing sink10 <br /> (2 or 3 comparhnents) Store frozen food � Vehicle wash facilities <br /> ❑Preparation of food IU! Hot&cold water for cleaning Eff'Totlet&hand washing Store refrigerated food <br /> Store dry foodlsupplies Provide potable water Q Overnight parking equate electrical outlets <br /> Signature of tommissa 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 /> 1& <br /> EHD 5 of 6 <br /> 06 017 MFPU APPLICATION <br /> EHD 1 <br />