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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): 1 <br /> Address for Vehicle: C ,, 11 —Cl ,— ` <br /> Street Address City <br /> 1) license Plate#: W 17 k Z� 4) Year: j y <br /> 2) Vehicle Vin#:14,j Make/Model.- <br /> 3) <br /> akelModel:3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: . )(^� Y -,`( Lc <br /> Address of Owner: =71, cun, {VAN Cit : I ci,5 <br /> street Addrass car <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 & 114290. 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 /> offiqe may result' p r revocation and penalties. <br /> � 7 G <br /> Si nature of Vehicle,Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: + L L S <br /> Owner Name: ,�V <br /> Site Address: , <br /> Street Ad s city <br /> Phone: 6� � ' <br /> I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> iquid&solid waste disposal tensil washing sink Store frozen food <br /> eh <br /> {2 o�com{�artments) ❑ tCie wash facilities <br /> Egffreparation of food Hot&cold water for cleaning �0�_TloiletA hand washing ❑ Store refrigerated food <br /> ore foodlsupplies []-Ffovide potable water Overnight parking FlWdequate electrical outlets <br /> i 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 /> Signature of County REHS Date <br /> Gun <br />