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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ,VEHICLE INFORMATION . <br /> _ E 'm <br /> I <br /> Vehicle Name (DBA): f C 6 11. <br /> I <br /> Address for Vehicle: ( O() V- "(- C'r J j �G rfG✓�c��v f—o <br /> Street Address 1, -10 <br /> city �y <br /> 1) License Plate#: ( N �) '1I� /,v 4) Year: Z 0( 7 <br /> 2) Vehicle Vin #: ( A (I (0 7 (0I 2 5) Make/Model: -5 S VAIV r"le') <br /> 3) State Decal #: A1 E/4- 6) Color: -",Id J" p <br /> _VEHICL'E OWNER INFORMATION A . 7. <br /> Name: Ve"h1 (1? tab✓a- <br /> Address of Owner: 5'S S-(. V. I Ati`j <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 esult in permit revocation and penalties. <br /> 12,1 11 <br /> SigrAulre of Vehicle O erator _ _ Date <br /> ,C MISSARY•INFORMATION _ _ <br /> Business Name: ( ^/ <br /> Owner Name: <br /> Site Address: UV L ��� ?6 <br /> Street Address city <br /> Phone: RSL) ' <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 /> P-Liquid&solid waste disposal �ensil washing sink tore frozen food �Cehicle wash facilities <br /> 12 or J compartments) <br /> t-1..Preparation of food ,Hot&cold water for cleaning la7oilet&hand washing 2-Store refrigerated food <br /> L�Store dry food/supplies Provide potable water �vernight parking aAdequate electrical outlets <br /> Signature of Commissary Owner/Operator Date <br /> iHEALTH DEPARTMENTo 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 go.r_ro�,e"At-0 <br /> County. <br /> X <br /> SignT County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/182008 <br />