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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: <br /> Street Address city <br /> 1) License Plate#: -rill�jg 0 61 4) Year: pq 5 <br /> 2) Vehicle Vin #: Make/Model: C ,1L�V <br /> 3) State Decal #: 6) Color: Wi'►/' <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: L G12Ll_ GSL -13/\[ <br /> Strdet 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 /> office may resu t in permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION ' <br /> Business Name: i? <br /> zc <br /> Owner Name: ' f ` <br /> Site Address: <br /> Str t ddress 9 / city <br /> Phone: ( ))� <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 /> �iquid&solid waste disposal Utensil washing sink [��fote frozen food M-1 <br /> Vehicle wash facilities <br /> (2 or 3 compartments) '✓�'\('"� <br /> ✓, Preparation of food 'a Hot&cold water for cleaning VToilet&hand washing 6 Store refrigerated food <br /> [!55tore dry food/supplies Q"Provide potable water Overnight parking 6Adequate electrical outlets <br /> Si nature ofC mmissa O ner/O erator Date <br /> HEA TH DEPA ss <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 />