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VERIFlr-ATION 00 V&E.HIrLE r0nnn,�����F;Y <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: 02- <br /> Street <br /> ZStreet Address city <br /> 1) License Plate#: "Z ?j- 4) Year: 440 <br /> 2) Vehicle Vin #: Make/Model: (-'71 ;�'C <br /> 3) State Decal #: G 6) Color: <br /> -VEHICLE OWNER INFORMATION <br /> Name: "( b-, Mtn Gl('?gofo <br /> Address of Owner: �?- flc[+I? l <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 /> S' ure of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: YVDF (*VO <br /> Owner Name: L <br /> Site Address: ►SRI Gl srZ C <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 /> L ❑ Utensil washing sink <br /> (2&solid waste disposal (2 or 3 compartments) 13 More frozen food Q Vehicle wash facilities <br /> ❑ Preparation of food [2Hot&cold water for cleaning �oilet&hand washing Q/Store refrigerated food <br /> E3 Store dry food/supplies ❑Provide potable water �ernighl parking [J/Adequate electrical outlets <br /> 0 <br /> Si nature o Commissar Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verity <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 G N1FPU APPLICATION <br /> 7/18/2008 <br />