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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): � ��� �/-� t l ,/?�L�G C fiJ 4 <br /> Address for Vehicle: /3 L 4 IV'1�14 L)?� fi( CX `-. :j�, 6 <br /> Street Address City <br /> 1) License Plate #: q6 1 1 3 R 1:?" 4) Year: S <br /> 2) Vehicle Vin #: 5) Make/Model: �Jf S Lt <br /> 3) State Decal #: 6) Color: JG G����%� Ci���!�� <br /> VEHICLE OWNER INFORMATION <br /> Name: J-Il u l e g N G S iiXp6f"(vjl <br /> Address of Owner: A 0 <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 /> ice may result in per `it revocation and penalties. <br /> 1 <br /> nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: Ll`Jf(l7 b' C 'fi is //L`6' �c'i/I C C c N -� <br /> Owner Name: - , T-uM 10 j 1 P A J <br /> Site Address: // .7 s - G `�16&1 ,S-T ,5-Tb <br /> Street Address 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 /> Liquid &solid waste disposal 9 Utensil washing sink dStore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ED-Oreparation of food L�j H of&cold water for cleaning [2Toilet&hand washing Store refrigerated food <br /> IDIE�tore dry food/supplies Provide potable water Overni t par ing Adequate electrical outlets <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 />