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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): <br /> Address for Vehicle: �j2®� S • Scy�c� ��v`�1��'�'l`3 S� �y 01S2 D <br /> Street Address City <br /> 1) License Plate#: (O tM2 5 G-� g 4) Year: q Q <br /> 2) Vehicle Vin#: Make/Model: C- <br /> 3) <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER.INFORMATION <br /> Name: (L ck�C-Kra Cv\o\ <br /> Address of Owner: j3� cjwtK�kpw L-+f\ , �- �� C j2 <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 /> CQMMISSARYINFORIVIATION <br /> Business Name: / 6y1 , <br /> Owner Name: 19 let o 0"W` <br /> Site Address: ZU q , Z Y,( A " <br /> Street Address City <br /> Phone: (7 d`() y— <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 /> Utensil washing sink Ef <br /> Liquid&solid waste disposal (2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> ❑ Preparation of food of&cold water for cleaningW4-6—flet&hand washing Store refrigerated food <br /> F[1re dry food/supplies rovide potable wafer vernight parking ULA quate electrical outlets <br /> Si nature of Commissary Owner/Operator Date <br /> HEALTHDEPARTMENT <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 /> 711812008 <br />