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VERIFICA"I IN OF VEHICLE COMSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VHHIGLEINFORMATION- <br /> Vehicle Name (DBA): <br /> Address for Vehicle: co, 9' ` <br /> Street Address city <br /> 1) License Plate#: 4) Year- <br /> � <br /> 2) Vehicle Vin#: tJ E4 ci5OalielMo4el: <br /> 3) State Decal * 3-7 6) Color: <br /> VEHICLE OWNER�INFORMATfDN 'Z <br /> Name: <br /> Address of Owner: b� <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 /> I office may result in p it r cation and penalties. <br /> Signature oicle Operator Date <br /> Business Name: "')C'Ae�'\ r �-lk-,:: <br /> Owner Name: <br /> Site Address: I i C,,& J— <br /> Street Address City <br /> Phone: <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 /> Liquid&solid waste disposal Utensil washing sink(Zor 3 compartments) J21'tore frozen food _D Vehicle wash facilities <br /> Preparation of food Hot&cold water for cleaning 01 oilet&hand washing 2 Store refrigerated food <br /> Store dry food/supplies Qi provide potable water Overnight parking -A-deuate electrical outlets <br /> 'Z El <br /> Signature of Commissary Owner/Operator Date <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 /> L L-- �j — �/ 2 6 <br /> '95nattke of d06, t REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7118/2008 <br />