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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name (DBA): y <br /> Address for Vehicle: <br /> Street Address <br /> 1) License Plate* � oZ � 4) Year: 20 , e'Z <br /> 2) Vehicle Vin#: /L���� (-C7C /9Q S�15) Make/Model: G 1's t-(L- <br /> _ <br /> 3) State Decal#: 6) Color: ►_xf..-y),W� <br /> Name: fti, `1 98(v - q3 <br /> Address of Owner: (o_ i cA o <br /> Street Address coy <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 ay result inpe it revocation and penalties. a <br /> f-�-' <br /> a- ZI <br /> Si tore Vehidiii O rator Date <br /> COMMIss- <br /> Business Name: z- - <br /> Owner Name: <br /> Site Address: �- <br /> Stroet Address city <br /> Phone: (2 ) l d <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 /> � ensil washing sink Store frozen food de wash facilities <br /> LJ �+�1UId&solid waste disposal (2 or compartments) <br /> reparation of food / Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> !0 <br /> fi Lc� food/supplies potable water fight parking quate electrical oLrtlets <br /> S' nature of Co mmt Owner/0 rator Date <br /> ft the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissarylfood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> 5 of 6 MFPU APPLICATION <br /> EHO 16-017 <br /> 7118/2008 <br />