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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: ; . 96 <br /> street Address City <br /> 1) License Plate#: 4) Year. 1gCI ( <br /> 2) Vehicle Vin #: �,[�1 jP3Z1SU{� Ig135) Make/Model: F,Q <br /> 3) State Decal#: 6) Color: hP <br /> VEHICLE OWNER INFORMATION <br /> Name+A �'Ia t - tt _ <br /> Address of Owner: 1S[�' .6 '� v Fctt ct <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 /> o�fficye may result in permit revocation and penalties. <br /> 141 JP <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 1 1 n; 1 <br /> Owner Name: (; <br /> Site Address: �, � <br /> Street Address city <br /> Phone: (Zt-)Il ) 2 ,7-1 <br /> — <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 /> duutensil washing sink �XStore frozen food Vehicle wash facilities <br /> Liquid&solid.waste disposal 0 <br /> r3 compartments) ,�/ <br /> separation of food Zot&cold water for cleaning Toilet&hand washinguStore refrigerated food <br /> Store dry foodlsupplies �rovide potable water Q Overnight parking [y]/Adequate electrical outlets <br /> Signature o ommissa Ow r perato 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 /> 7118/2008 <br />