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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 J city <br /> 1) License Plate#: 2,E 1 4) Year: 2 o 17 <br /> 2) Vehicle Vin#: 30 $) Make/Model: <br /> 3) State Decal #: (� 6) Color: G <br /> VEHICLE OWNER INFORMATION <br /> Name: N <br /> Address of Owner: 5 (t,F}Y►l w-5 t, WY--A-oN <br /> Street Address city <br /> The mobileIfoleaning <br /> ty shall operate out of a commissary and shall report to the commissary at least once each <br /> operating dand servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinuIder must notify this office to make the necessary changes. Failure to notify this <br /> office may revocation and penalties. <br /> G 1112017 <br /> Si natureAO/ is Operator) Date <br /> COMM14FQRMATfqN <br /> Business ' <br /> ame: GL D ��t'c c <br /> Owner Name: �j , <br /> Site Address: �� t/lt ' (tel t� �U �> <br /> St bet Address 61 city <br /> Phone: a - S'20 <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 19 Utensil washing sink ❑ Store frozen food ® Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food -Hot&cold water for cleaning ® Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Stofe dry food/supplies lK Provide potable wat r Overnight parking ®Adequate electrical outlets <br /> Signature of Commi a Owner/Operat Date <br /> HEALTH DEPAR MENT <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 />