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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICI_E.I F0_ AMATl0I>( <br /> Vehicle Name (DBA): <br /> Address for Vehicle: ';7 1. --"-r (c- <br /> Street Address , city <br /> 1) License Plate#: - f-✓-1-C7`/^`i 4) year: J <br /> 2) Vehicle Vin#: e-P L� 3 00C(L F� 5) Make/Model: ��/���✓ <br /> 3) State Decal#: 6) Color: W ; - -- <br /> Y ;r-liOlE ' lidEK <br /> Name: <br /> Address of Owner. �1' C <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 (CaiCode sections 114296 & 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 /> office may result in permit revocation and penalties. <br /> i nature of Vehicle Operator Date <br /> C_+0MMW66AR`f�lVljO�lU1AT l,�t_ n - <br /> Business Name: Lk c <br /> Owner Name: <br /> 0.4 <br /> Site Address: 730 <br /> Street Address city <br /> Phone: Ov�) 1 �� 1 �� _Z1 P <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 /> ' <br /> quid tensil washing sink&sclid waste disposal (2 or 3 compartments) ❑ Store frozen food ehicfe wash facilities <br /> LD,P7e-paration of foodof i cold water for cleaning oilet-&hand washing ❑ Store refrigerated food <br /> Jodry food/supplies rovide potable water vernight parking . _equate electrical cutlets <br /> i <br /> � c [7 <br /> Signature of Commissary Owner/Operator Date <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 /> EHD 16-017 5 ;o^ NIFPU APPUCATIC—N <br /> 7/1812008 <br />