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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 CL <br /> Address for Vehicle: <br /> NL� lmvt <br /> C� <br /> Street Address city <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE,.OINNER`.;I.NFOR <br /> NATION , <br /> Name: <br /> s lC1 C1tZ,, <br /> Address of Owner: L <br /> Street Addressy <br /> 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 /> co 11 ba <br /> Si n ture o e icle Operator Date <br /> COMMISSARY INFORM ... <br /> ATI ON <br /> Business Name: <br /> Owner Name: <br /> Site Address: ., 'li 0 <br /> Street Address City <br /> Phone: (1Cc�i) _ <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 21 Utensil washing sink <br /> (2 or 3 compartments) Store frozen food ❑ Vehicle wash facilities <br /> ❑ Preparation of food ZHot&cold water for cleaning Toilet&hand washing F7T Store refrigerated food <br /> ❑ Store dry food/supplies qrProvide potable water Z Overnight parking Adequate electrical outlets <br /> Signature of Commissary ner/Operator Date <br /> u <br /> HEALTH�DEP;4RTMENT ', <br /> If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br /> current health permit by signkpg below. Commissary/food establishment is in <br /> County. <br /> Signature of County Ff�-KS Date <br /> EHD 16-017 5 of 6 <br /> 7/18/2008 MFPU APPLICATION- <br />