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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): 4 4 P <br /> Address for Vehicle: 3' 1nl C_ 6tf 1U IY S �)C rf�� C� GJ' �2 q <br /> Street Address cify <br /> 1) License Plate#: � X Sq/3 C) 4) Year: -/ 2 -77 <br /> 2) Vehicle Vin#: 5) Make/Model _045-1 -QZ�T <br /> 3) State Decal #: 6) Color: W (t 1 Tt <br /> VEHICLE OWNER INFORMATION <br /> Name: ,p1�� lLG <br /> Address of Owner: 2 f)�3- <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 /> 1 43 V 6- <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> BusinessName: <br /> Owner Name: <br /> Site Address: LM! 2t ,rC ��rtf C 15 d� <br /> 26(� Street Address City <br /> Phone: ( / ) _ 9 & - 1-5 <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 /> 1p <br /> Liquid&solid waste disposal E=1 utensil washing sink tore frozen food �ehicle wash facilities <br /> (2 or 3 compartments) <br /> tPreparation of food PHot&cold water for cleaning Q Toilet&hand washing Store refrigerated food <br /> Store dry food/supplies Provide potable water Overnight parkin Adequate electrical outlets <br /> / G <br /> Si nature of Commissa 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 />