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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): I; ' �,F, 7 S'' S' Si`JZG;4 1Jy'LCl. <br /> Address for Vehicle: .S 7)C4_ (�� S�L- <br /> - > �� <br /> �—Street Address city <br /> 1) License Plate*/V 4) Year: ; <br /> Z) Vehicle Vin#: 5) Make/Model: , %% <br /> 3) State Decal#: j 6) Color: <br /> VEHICLE OWNER INFORMATION .. <br /> Name: /y' `� '\�� 9A / .) <br /> Address of Owner: 'SO'T 46 A 'I-- r /4 2 6 <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 /> office may result in permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ) C1 ? X66�&7-e- SCG ,SCJ LL v� <br /> Owner Name: i l/l- <br /> Site Address: ��' (,V L-S 1 . �,�I iVz�� /C16 <br /> Street Address city <br /> Phone: (� P 2 A-2- <br /> 1, <br /> Z-1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below:: yam, <br /> ❑ Liquid&solid waste disposal LJ"6tensil 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 tore refrigerated food <br /> ❑ Store dry food/supplies ❑Provide potable water Overnight parking ❑Adequate electrical outlets <br /> ZI 0� z—i'4Zlc 'Z / - , <br /> Signature of Commissary 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 /> 7118/2008 <br />