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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 City <br /> 1) License Plate#: 7 F� �, 4 Year: <br /> 2) Vehicle Vin #:qelzG`7��ZvZC)l Lo %�, 3� Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: zc' / <br /> Address of Owner: �� •J O z , rk 5 55; j <br /> Street Address J 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 /> ,,a `-- , /i�/ �-�/ <br /> Signature of Vehicle Operato( Date <br /> COMMISSARY INFORMATION <br /> Business Name: -L <br /> Owner Name: F <br /> Site Address: <br /> Street Address city <br /> Phone: J <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 /> i <br /> squid —solid waste disposal ensc washing sink ore frozen food Vehicle wash facilities <br /> • (Z or 3 compartments) <br /> Preparahh f-food D+Iot&cold ter for cleaning [ oiiet&hand washing re refrigerated food <br /> to e"¢ry food/supplies rovide potable water n Q i ht p� uate electrical outlets <br /> Z f <br /> /o <br /> ,Signature <br /> Si nature 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 />