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VERIFI TION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): :y L re Gn <br /> Address for Vehicle: O S4-r-)(- <br /> Street <br /> (- <br /> Street Address City <br /> 1) License Plate#: �� �,� � �_ 4) Year _ I C __ <br /> 2) Vehicle Vin# MZS, /p Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION (' <br /> Name: a(� ; rnC,►de z <br /> Address of Owner: al oe LA Ck <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 /> offs a permit revocation and penalties. <br /> l' <br /> a re of V77icle erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: e <br /> Owner Name: <br /> Site Address: �lIZ2 cG <br /> Street address City <br /> Phone: (z O Ciel/ / / <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissa as checked below: <br /> Liquid id waste disposal tensil washing sink ❑ Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments► <br /> Pr <br /> of food of&co ter for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> to food/supplies rovide potable water Ovemight parking deguate electrical out!ets <br /> Z_/'/`�//7 <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 /> Signature of County REHS Date <br />