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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: <br /> Street Address uny <br /> 1) License Plate#: (51j-7-6 J/ ,!Z 4 Year: <br /> 2) Vehicle Vin#-*-vel 2G'7� �vZCJl f�, j Make/Model: jZf fh <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <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 permit revocation and penalties./ <br /> Signature of Vehicle Operato(' Date <br /> COMMISSARY INFORMATION <br /> Business Name: �ll�r GJ c <br /> F� <br /> Owner Name: <br /> Site Address: cam) i' <br /> Street Address / city <br /> Phone: (2 ' ") „ / 9,7UZ <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 /> EJ-G�quid&solid waste disposal ensil washing sin0-8 k <br /> (2 or 3 compartments) ore frozen food0—vehicle wash facilities <br /> ��Preparati'o - food [ZKot&cold ter for cleaning D Teifet&hand washing 0-S{ofeefrigerated food <br /> to 6�lry food/supplies rovide potable water [�,l3vetn'ight parking equatele ectrical 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 />