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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> WN <br /> g <br /> '0 N M" <br /> VEHICLE NFOR" <br /> Vehicle Name (DBA): Ix,A <br /> Address for Vehicle: <br /> Street Address <br /> 1) License Plate#: qS G SS 4) Year: eq <br /> 2) Vehicle Vin#: Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Ownery. <br /> treat 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 .cing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, the-permit holder m st ,otify this office to make the necessary changes. Failure to notify this <br /> offic�rnay resull in.permit re4ocati 'n and penalties. <br /> Signate of Vehicle Operator"— Date <br /> I'VE <br /> COMM iSgARY]NIFORMAT[ON <br /> Business Name: ' Cn&'Q�ZC'-'\0'\ <br /> Owner Name: <br /> Site Address: N00 e . Kaca-NnaL � op Ce q!5 20 5 <br /> Street Address city <br /> Phone: (ZOLA) <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 /> Liquid&solid waste disposal Utensil washing sink f- ❑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 /> F-1 S dry food/suppli Provide potable water Overnight parking FK]Adequate electrical outlets <br /> Signature of ComVnissary Owner/Op4dfor Date <br /> DEPARTMENT HEALtWDEPA, <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 MFPU APPLICATION <br /> 7/1812008 <br />