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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): r i <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: L ?�G?)14) Year: i CLC( <br /> i <br /> 2) Vehicle Vin#: Make/Model: -tAEi1 <br /> 3) State Decal#: 6) Color: l i-k(F� <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: <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 /> ict Q- K",A t ( - <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 7 no 1 <br /> Owner Name: o <br /> Site Address: 3(A- x&6:�j �toi �t <br /> Street Address city <br /> Phone: (Z7W ) 2 - <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 /> dUtensil washing sink Store frozen food Vehicle wash facilities <br /> uld&solid waste disposal or 3 compartments) <br /> reparation of food [ Hot&cold water for cleaning L9/Toilet&hand washing Store refrigerated food <br /> &Store dry food/supplies �rovide potable water U Overnight parking Adequate electrical outlets <br /> Si nature o ommissary Ow r perato 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 ofe MFPU APPLICATION <br /> 7/18/2008 <br />