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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: ,7-c, t-, azwc .S 6ckT0/LJ C/f QS"Z 6 6 <br /> Street Address city <br /> 1) License Plate#: d (6 4) Year: 19 7 <br /> 2) Vehicle Vin#: T/�L3�� z 78� 5) Make/Model: Ciro <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: ; &612b ZX Q <br /> Address of Owner: 62C, E , C Ld 5'7� -57VCXTO U <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 permit revocation and penalties. <br /> Z-//-S <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: © G"t'71-E -1WJAL:K C�111TF�2 <br /> r <br /> Owner Name: ,Q <br /> Site Address: 1717 S. u !' d of S C- 57-0L TvA <br /> Street Address City <br /> Phone: (?C�) ITT-- <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 tore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> [D'�reparation of food Hot&cold water for cleaning oilet&hand washing ore refrigerated food <br /> Store dry f d/supplies -Provide potable water abvernig�ht parkin Adequate electrical outlets <br /> Signature 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 />