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VERIFICP PION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): U <br /> Address for Vehicle: <br /> tree Address city <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin #: UOU05) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: Oc ` qaj <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 /> office may result in permit revocation and penalties. <br /> z 6 ( 0 ( <br /> ignature of Vehicle Operator Date <br /> COMMISSARY INFORMATION _ <br /> Business Name: <br /> Owner Name: Y- _ 1 - <br /> Site Address: ZU4U ,Q1r Qbrt- tau �v�v �-u/) __ <br /> Street Address City <br /> Phone: ( ) Z 1 <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 /> Wiquid&solid waste disposal Utensil washing sink(2 or 3 compartments) Store frozen food [ Ve icle wash facilities <br /> Preparation of food �ot&cold water for cleaning Toil &hand washing ?Adequate <br /> re refrigerated food <br /> Store dr food/supplies Provide potable water <br /> Y Overnight parking electrical outlets <br /> 16 /Icy <br /> Signature of Commissa O\A7ner6p-6r-a-T7o!p 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 3 MFPU APPLICATION <br /> 7/18/2008 <br />