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RECEIVED <br /> VERIFICATION OF VEHICLE COMMISSARY AUG 0 6 2019 <br /> Please provide all information requested. An incomplete application may delay <br /> "6NMENTAL HEALTH <br /> VEHICLE INFORMATION S <br /> Vehicle Name (DBA): / r <br /> Address for Vehicle: <br /> Street Address ` �J <br /> City <br /> 1) License Plate#: V'5 Z,-,)%-':9 4) Year: f47 <br /> 2) Vehicle Vin#: !> i�.L1 y ,� s" YF 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE O ER INFORMA N <br /> Name: <br /> Address of Owner: <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,potify this office to make the necessary changes. Failure to notify this <br /> office may result in per catio nd penalties. <br /> Signature of Vehicle Of2piator Date f <br /> COMMISSARY INFORMATI <br /> Business Name: d- <br /> Owner Name: ' <br /> Site Address: <br /> Street ddres City <br /> Phone:. <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 /> It <br /> c <br /> Liquid&solid waste disposal LSI Utensil washing sink <br /> (2 or 3 compartments) Store frozen food❑ Vehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑S dry food/supplies [ ] Provide potable water <br /> ❑ Overnight parking ❑Adequate electrical outlets <br /> Signature of Commi sa Owner/Operat ' 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 <br /> 711812008 MFPU APPLICATION <br />