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VERIRCAT�ICOI�� OF \!, F-,H!rLE C-110MMISSARY <br /> Mepse provide all information requested, An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: 2- 4 21,; \K) 6L "D <br /> ;, <br /> Street Address r c , <br /> 1) License Plate#- 5A k 4) Year: <br /> 21 Vehicle Vin #: <br /> 4 5) fvlake/Model� <br /> _2j�qR3_ -—----- <br /> 3) State Decal #: S©0 Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: c UclU 1,3 &U <br /> Address of j'ZQ eA\ <br /> I <br /> Street Address city I <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 (CafCode sections 114295 & 1142971. 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 /> Sig ture oTVehicle Operator Date' <br /> COMMISSARY INFORMATION <br /> Business Name: te.1%RPh i 0jhA <br /> Owner Name: <br /> Site Address: 2,Y4(> Ak? ( �0 C' <br /> Street Address city <br /> Phone: (2c/1 ) 2 I - % 7-q <br /> 1,the commissary owner, can and will provide*,P necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> N/Liauid&s-.!id waste 6sposal U,tenS!1 Wa 5 h,i!-.g S n X-ore t'CW Vehicle wash fadli,'es <br /> (2 or 3 compartrntntz) <br /> Preparation of food Fq4t&cold:nater for c!,eanirc i TcHet hand washing 1—! S' -e refrigerated food <br /> 140re d!-v foodfsup, <br /> SignatOR-�oCo MISSaFy Owner/ Brat! Date <br /> HEALTH DEPARTMENT <br /> If the commissary/fbod 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 /> dk <br /> Signature 0-iCOUntV RENS Date <br /> EHD 16-017, <br /> 71181200.3 <br />