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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: 2 20 <br /> Street Address vity <br /> 1) License Plate* /�$ 7 3 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: /� <br /> 3) State Decal#: 6) Color: /C 2 <br /> VEHICLE OWNER INFORMATION , / <br /> Name: � eyvt `( l <br /> Address of Owner: z Z ED 6�7 5 o'1/61' IIb ST Sr GK d k) 61 9-5.2 <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 CaiCode sections 114296 & 114297). if the use of the commissary is <br /> discohti ed, the permit holder mus tify this office to make the necessary changes. Failure to notify this <br /> office y result in permit re and penalties. <br /> �j 3 / <br /> nature of V cle O rator Date <br /> OMMISS Y INFORMATION <br /> Busine ame: Oftj G <br /> Owner Name: <br /> Site Address: S. 199/ ;S7- STOCK O/� G/7 <br /> cY street Address city <br /> Phone: <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 /> Liquid&solid waste disposal Utensil washing sink [Ztore frozen food 0ehicle wash facilities <br /> I-I 122 or 3 compartments) <br /> separation of food D not&cold water for cleaning �oilet&hand washing r� Store refrigerated food <br /> Store dry food/supplies �,IDvttle po mie water vemig t parking L�-rAaequate electrical outlets <br /> Si nature 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 /> \ 7/18/2008 <br />