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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 <br /> Address for Vehicle: <br /> iii. ��✓i i <br /> S reet Address City <br /> 11 License Plate#; ��{����'�;7 Z� ave a r: 7n,ti <br /> 2) Vehicle Vin#: Make/Model.- 1`,' <br /> 3) State Decal#: 6) Color: A 6L", 5`- <br /> VEHICLE OWNER INFORMATION <br /> Name: //V <br /> , ' <br /> Address of Owner: <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 /> r1� <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: - <br /> Owner Name: <br /> Site Address: 1 <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 <br /> (2 or 3 compartments) ❑ Store frozen food ❑ Vehicle wash facilities <br /> ❑ Preparation of food F-1-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 /> Signature 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 RENS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />