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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: —7 ( Ct X - �, --5111� <br /> Street Address Ci <br /> 1) License Plate#: �j - �0�5 4) Year: f J <br /> 2) Vehicle Vin#: *L"'XIP39--eV6 :3—�b {g35 5) Make/Model: (f <br /> 3) State Decal#: 6) Color: J „�fp <br /> VEHICLE OWNER INFORMATION ��— <br /> Name: e h // <br /> Address of Owner: 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 /> officema result in permit revocation and penalties. <br /> �6;27� <br /> fign&6re ofe Icle Opeaffir Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> �v'�G�K &16 <br /> Owner Name: <br /> Site Address: <br /> Street Address City <br /> Phone: v;7 / 75l/ <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 /> Liquid&solid waste disposal [ i `^'ashing sink f❑ Store frozen food V ash facilities <br /> (2 or 3 compartments) <br /> ;��Prep ion of food of&cold water for cleaning FTDjJ,&t-&1'fand washing ❑ Store refrigerated food <br /> Stor food/suppli s Ovide potable water vernight parking ®^Ad q�uate electrical outlets <br /> 01"ignature of Commissary 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 />