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V ERIFICATIC)NI OF VEHU."J.-i""' �`OMMISSARY <br /> P;—s- vrovidle -211 !--C,-p?SteC,4, 'at- may delay approv <br /> r <br /> Vehicle Nla.Tie (DSJ1.): icos <br /> \L L <br /> Address fo;. Vehicie- <br /> 3 t r c-Tt_Ac�d_re_ss <br /> (,Par <br /> 1) License Plate Q 13 <br /> 2) Vehicle Vin 4: 3 a L"ez,'M c d e!i I Lq6?0 <br /> 3) State Decal #: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> AddressF 0�v;ner: <br /> S4 cc V4,6 v) <br /> The mobile food facility shall operate out of a cornimissary and shall report tothe commissary at leas -,ach <br /> operating day for cleaning and serilcing (CafCode sections 114^495 & 1142971. !f the Use Of the cor� ssary is <br /> discontinued, the permit holder must notify thl, off7ce to the necessary changes. Failure to rl.-)tify fhls <br /> office may result in permit revocation and perialdes. <br /> Signature of Ve!N;c;_- Operator Date <br /> COMMISSARY INFORMATION <br /> BUSin-ss Niame: Q r In, <br /> Owner Name: <br /> Site Address— <br /> Street Address <br /> Phone: ?, rj ) <br /> ) 7 77A - 17: q ------ <br /> !, the commissary owner, earl and will providett-ir- necessary facilities for jhe above mentioned viehic!eat n1v <br /> Commissary as checked below: <br /> VLicuid.?, sc!id <br /> , enS ve;nide m_:S1, pcz <br /> a�.�;,r,of i Dod &7,otj !'-le!,T"O.,�­-Sr"­l <br /> 17<10re dry <br /> Dat,e <br /> HEALTFi DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County. the loc?l healfli .iurisdiction rnust veHfy <br /> current health *erm.lt by signing below. Corn nnis-saryfood establishment is in <br /> County. <br /> Signature of County RENSDate <br /> EH.D 1::;-Q 17 <br />