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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: M) <br /> Street Address city <br /> 1) License Plate#: �) Year: <br /> 2) Vehicle Vin#:/�(; ���,;��� S 3`��� �) Make/Model: <br /> 3) State Decal#: 6) Color: I <br /> VEHICL.E._. WNER INFORMATION �^ <br /> Name: <br /> Address o Owner: <br /> 5tree Address Clty, <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 /> b"o 1 <br /> Stghature of Vehi e Operator Da e <br /> COMMISSARY INFORMATION - <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> Street Address City <br /> Phone: (a,c>q' ) 4CGSC 2ZZ 171711 <br /> 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary sas checked below: <br /> [71�ensil washing sink <br /> [�'Liquid&solid waste disposal <br /> (Z or 3 ynmpartrnentsj ore frozen food 0•1Gehicle wash facilities <br /> [Afreparatiori..of-foodiot&cold.water for cleaning Q h et&hand Washing ❑ Store refrigerated food <br /> ®",Store dry food/supplies [JFf6vide potable water ©might parking dequate 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 />