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VERIFICORON OF VEHICLE CO"ISS <br /> ARY <br /> Please provide all information requested. Aincomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: �� \C'N�QS <br /> Street Address city <br /> (� S 1 <br /> 1) License Plate #: � `� � 4) Year: <br /> 2) Vehicle Vin #: V zf -t� � �5) Make/Model: <br /> 3) State Decal #: C�6 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: ��t °ia�1 — � M�� ��� � <br /> Address of Owner: ® O ki\- \j CP� <br /> Street Address I 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 /> office may result in permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: '�L `� 3y� �^`� k��� � <br /> Owner Name: WN-�Ty <br /> Site Address: <br /> Street Address <br /> Phone: (Mi 144 1 <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 /> a disposal �� <br /> Li uid&solid waste EJUtensil washing sink <br /> q (2 or 3 compartments) I Store frozen food Q Vehicle wash facilities <br /> Preparation of food 0 Hot& cold water for cleaning ® Toilet&hand washing Store refrigerated food <br /> 0 Store drypplies Provide potable water NOvemight parking Adequate electrical outlets <br /> Sig nature of Commi a Owner/OperatK 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 />