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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMIAnQN.ah <br /> Vehicle Name(DBA): —t `— <br /> Address for Vehiclec <br /> sb.etAadnm CIV <br /> 1) License Plate#: - SSC> kC 4) Year. ZE) <br /> 2) Vehicle Vin#: Make/Model: <br /> 3) State Decal#: 6) Color: ,1c k <br /> VEHICLE DINNER INFORMATION- <br /> Name: < d o <br /> Address of Owner G 2 t Y !J 12� �f7Ck C Leo <br /> street Address qty <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 (CaiCode 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 /> Si nature of Vehicle O rator Date <br /> COMMISS _.TION_ <br /> Business Name: Su <br /> l- <br /> 0"Name: L1 <br /> Site Address: 1 I 2 <br /> cay <br /> Phone:(ZoH ) W 3 <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 /> u Liquid&solid waste disposal iJ Utensil washing sink - �{r en food �Vehide wash facilities <br /> r- t22or3compartments) <br /> ❑Preparation of food (_urfiot&mld water for cleaning l TT ilet&tend washing refrigerated rood <br /> Store dry fooftupplim �rovide potable water L&uverright parking [7 <br /> [equate elechical outlets <br /> SiSi tuaneofCommissa Ownedoperator 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. Commissaryftod establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of s <br /> 7118120086-0 MFFU APPLICATION <br />