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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all inlyormation requested. An incomplete application may delay approval. <br /> VEHICLE INI=ORMATION <br /> :. <br /> Vehicle Name (DBA): ' <br /> Address for Vehicle: e, <br /> streetddress City <br /> 1) License Plate#: !, S 4) Year: _ <br /> 2) Vehicle Vin#: ! 37�z dp9149 5) Make/Model: <br /> 3) State Decal#: G) Color: <br /> VEHICLE QWNER.INF4R_MATt4N <br /> Name: <br /> 11"1"1 ,4 lee- <br /> Address of Owner: 3 01 f, Y arc f Aa <br /> Street Address ;ty <br /> The mobile flood facility shall operate out of a commissary and shall report to the cornmissary 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 hermit holder must notify this office to make the necessary changes. f=ailure to notify this <br /> office may result in per ation and penalties. <br /> Signature of Vehicle Q66fator Date <br /> D OMMIS$ARY,.IN FORMATION,_.,. <br /> Business Name: L ?. t <br /> Owner Name: <br /> Site Address: <br /> StreetAddress Ucity <br /> Phone: Lt 5-� <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 sink <br /> J2 or 3 compartments} ❑Store frozen food ® Vehicle wash facilities <br /> ❑ Preparat�onk of food ]Hot&cold water for cleaning ©Toilet&hand washing ❑ Store refrigerated food <br /> tore ry foodlsupplies ®Provide potable wate_ overnight parking [Adequate electrical outlets <br /> F <br /> � 40�1 /a -'�z Y <br /> Signature of Commi`ssa Owner/Ope(afor Date <br /> HEAI:TH DEPARTMENT <br /> If the commissarylfood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissarylfood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD40-077 5 afS <br /> 7118!2008 MFPU APPLICAMN <br /> 7118 , <br />