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v <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> 1A <br /> Vehicle Name (DBA): - 2 <br /> Address for Vehicle: ScicorAwcl S Zt <br /> c <br /> Street Address city <br /> 1) License Plate#: to (A LO 1 Ll 4) Year: f 1 (s <br /> 2) Vehicle Vin #: (bDI` 5) Make/Model:% <br /> 3) State Decal #: 6) Color: <br /> Name: � r <br /> iz ue- G. <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 permitrevocationand penalties. <br /> Signature of Vehicle O erator <br /> Date <br /> . «N7M 73' <br /> 11 <br /> Business Name: <br /> Owner Name: Co , (o 1 e AA` <br /> Site Address: O S , J� S <br /> Street Address <br /> Phone: 7 22, city <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 <br /> (2 or 3 compartments) ❑Store frozen food Vehicle wash facilities <br /> ❑ Preparation of food t&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑Store dry food/s plies ovide potable watervernight parking %Adequate electrical outlets <br /> O <br /> Signature of Commissa O nr eratori / <br /> Daete <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 /> Sign"ture of C6unty RE H8_ Date <br /> EHD 16-017 <br /> 7/18/2008 5 of 6 MFPU APPLICATION <br />