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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): j'^ j,1 , `all - , <br /> Address for Vehicle: <br /> e <br /> Street Address city <br /> 1) License Plate#: 4) Year: a2— <br /> 2) Vehicle Vin #: Make/Model: <br /> 3) State Decal #: 6) Color: to n <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> i <br /> Address of Owner: Jenen 0 � <br /> St et 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;'th permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office r t In permit revocation and penalties. <br /> Si nature of Veh Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: ;k14 Ir Q <br /> Site Address: ( <br /> Street Address City <br /> Phone: (-2 ' 6 <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 [41Utensil washing sink <br /> (2 or 3 compartments) 'Store frozen food Vehicle wash facilities <br /> VPre ration of food Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> dry food/supplies rovide potable water Overnight parking Adequate electrical outlets <br /> Signa ure 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 REHS Date <br /> EHD 16-017 5 Of 6 MFPU APPLICATION <br /> 7/18/2008 <br />