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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application roval. <br /> VEHICLEmay delay approval, <br /> i <br /> INFORMAT►ON <br /> Vehicle Name (DBA): <br /> Address for Vehicle: �' <br /> L <br /> 3 a C� n; v* , <br /> Shcet Address <br /> 1) License Plate#: p1G Ca 4) Year: <br /> 2) Vehicle vn#: P32KcP3�9-ayo 5) Make/Model: �1 <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: 3o <br /> C3 R,iC t <br /> street Address city <br /> I <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 /> off e mpy result in permit revocation and penalties. <br /> ck J L 30 <br /> Si nature g Vehicle Operator Date <br /> j COMMISSARY INFORMATION <br /> Business Name: l }ry <br /> Owner Name: ON C-y' <br /> j Site Address: 2�f` CIS? I J street Address / <br /> Phone:(q/6) a city <br /> I,the cgmmissary owner,can and will provide the necessary facilities for the ijbove mentioned vehicle gt My <br /> commissary as checked below: <br /> Q-lAuid&solid waste disposal 4-Utensil washing sink <br /> i[or 3 compartments) [B-store frozen food Q-Vehide wash facilities <br /> Q-Pteparatlon of food QJiot&cold water for cleaning Q T91lel&hand washing [:]-Store refrigerated food <br /> ©'Store dry ood/supplies .Prov de potable water Int <br /> n �n W.uvemght paTing © <br /> Si natureOfC miss'a}l .Atl�uate electrical outlets <br /> `lVv— <br /> Owner/0 Owner/operator Date 3c <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health <br /> current health Permit by signing below, Commissaryffood establishment is In <br /> Court <br /> Jurisdiction must verify <br /> Signature of Coun EHS0 <br /> Date <br /> END 16-017 <br /> 7/1&rmp6 <br /> 5 of <br /> MFPU APPLICATION <br />