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Nov 1 Q VERIFICATION OF VEHICLE COM SSARV 10 2015 <br /> prro`ride atf bftff ntkm requested. An incomplete application may daisy a#prov$t. <br /> EMARONMENTAL HEALI H <br /> Addfws <br /> W vetkie: CRY <br /> Acklra�s <br /> 1) License Plate#- -- — 4) Year: ____--- <br /> 2) Vehicle vin#: C e�435 <br /> - <br /> 3) State Decal#: - S) Color: <br /> Name; - _7,C�97Y/Z) --- <br /> AddMM of 4� ►r: 02 C. �cv _ G Z_T.__ ���� C� i�� --- <br /> s~address cfty <br /> The mobile food fmiiity shall opwaW alt of a coininbsary and shah report to the commissary at least once each <br /> operaEting day for cleaning and servicing (CalCode sections 114295 ll; 1142E+7). if the use of the commissary is <br /> discaidi ued. t#B Pig holder must natftty Uft o?fte to make the necessary Changes. !=ailuro to nosy alis <br /> off may resod in permit revocation and penalties, <br /> 1=OA-/k <br /> f Vehicle .OperdtDr Date <br /> Bushim : <br /> r�tarne: <br /> s Ants: - <br /> s� -.-� �_. - - --w <br /> 1,the c9mmissary owner,can and wht provide the necessary facilities for the above mentioned vehicle at MY <br /> commissary as checked below: <br /> i <br /> iquid It said waste dia� tem Thor sj!1;6% � Store frozen tC,aG U eftrzfe Wash faOisrir_Y <br /> (Z*F3 i <br /> Z- of food Zi cnid er for deanmg P'7 Deet&Fund washing ?- Stare refngesatea ftxc <br /> � uate efecscsl cxie <br /> potable water ��+��►n pw�" <br /> i <br /> Of Corrxztiss C?rtrcrertQperaEtor Date <br /> HIEALTH DEPARI#IENT <br /> if the coMMhMryfl'ood e8t&bftl1r*E"t is outskte San Joaquin County,the local health jurisdiction most vent}+ <br /> eufr+ent.heakh peal*by signing below. Cormsissaryifood establishment is in �---- <br /> County. <br /> f <br /> Signature of County RENS Date <br /> Elia!I"-I T 3 01 6 MFPfj APPt fCATlprt <br /> 171WOW <br />