COMMISSARY

COMMISSARY NAME

COMMISSARY ADDRESS

COMMISSARY PHONE

COMMISSARY PERMIT EXPIRATION DATE

COMMISSARY LOCATED IN COUNTY.

COMMISSARY IS INSPECTED AND PERMITTED BY

The following business has permission to use this establishment as a Commissary:

Vehicle Business Name

Vehicle License Number

Vehicle Identification Number

Address on Vehicle

Name of Owner or Operator

Address of owner if different than what is on vehicle

This Commissary will provide the following functions:

Supply food products

Store frozen foods

Store refrigerated foods

Store dry food and food related products

Cleaning and service operations

According to the California Uniform Retail Food Facilities Law, Section 27672(f), the vehicle is to operate out of an approved commissary. The vehicle is to report to the commissary at least once each operating day. If the operator discontinues use of the commissary, it is necessary to notify this Department to facilitate proper changes - such as change of address or ownership which Invalidates permit and commissary letter.

Signed Date

(Commissary Operator)

F-37