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VERIFICAT[ON OF VEHICLECOMMISSARY <br /> plEEiaa ir3-rovide all information requested. An incorr!plete F-PP ICatiGn i[tai° Y <br /> VEHICLE INFORMATION <br /> Vehicle kd3crte(DGA}: <br /> Address for Vehicle: 7,3 O <br /> SU)aet Address cfty <br /> t) Ueense Plate* ��� � f o� 4} Year: /9 - <br /> 2) Vehicle Vint#: C j 5" 3 ��t 6 } Make/Modell- <br /> 3) <br /> ake/Model:3) State Der-a(#: 6) Color: <br /> f - <br /> VEHICLE OWNER INIFORMATION � <br /> %dd-'a S of 11 x ice <br /> pjy �7i c.lY <br /> s _addms City <br /> Che mobile food facility stmt€operate out of a commissary and shall report to the commissary at least once each <br /> operating day for cte- Ing and ser'ricirfg (CalC cscia sections t.426SS & 114297). if the use of the co'.3'cnissary Is <br /> discontinued; the E Y It holder must notify this office to make the necessary changes. Failure to notify this p <br /> Gffi r ay It i D it revocation and penalties. <br /> • 6; / <br /> SiOnkUP6 of Vehicle Operator Dfa:cs <br /> COMMISSARY INFORMATIOt4 � <br /> Business Name: <br /> Owner Name: S <br /> Site address: _• � �� ' � , �' � /� <br /> € 3�eet/kddc2ss tarty s <br /> C Phooe: <br /> is 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 /> / <br /> Liquid solid waste disposal ensil washing sink ([I Store frozen food %e?►icle wash s <br /> — (2 or 3 tatenfs) <br /> E <br /> Preparati food �ovideeepo�table <br /> ter for cleaningnmight <br /> et&han -washing Store r rigsrated food <br /> dy foodisupplies mazer parking MAdequate electical ousts <br /> e� 1� <br /> Si nature 6f torrimissary Owned0 erator Date <br /> HEALTH DEPARTMENT ) <br /> If the commissarylfood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> corm nt health permit by signing below- Camrnissary/food establishment is in <br /> County. <br /> Signature of County-REHS n�. <br /> s <br />