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VERIFICATION O "VIEHICLE COMMISSARY <br /> F�E�se provide all information requested. An inco€raf►€et�apislecatican may delay approval. <br /> IM <br /> Vehide name (DBA} _ <br /> Address for Vehicle: r _ e <br /> suet <br /> ) License Plate#: c!�F &734�l 4) Year: Z2; <br /> 2) Vehicle Vi^#:f G' � i 3/���S/ ) fiakelodel: C' <br /> I — _ <br /> i'Mil <br /> - _ 4; •1W0 <br /> Ad-dress of Owner.- /7:>2,3 S. �t/�!S' l�✓�fl .� G r� G-J4 �`�s�S <br /> Sbee Address city <br /> The mobile food facility shall operate out of a commissary and shall report to the cornmissary at least once each <br /> operating day for cleaning and servicing (CaiGode Sermons 11429_ & 11=7). if the usse of the comrmssary is <br /> discontinued, the permit holder must notify this office to make tate necressary changes.. Failure to notes this <br /> office may result in permit revocation and penalties. <br /> Sicinature of Vehicle Operator Date <br /> � .. /— sem_/ ��iT`�.1�-�,� '�nH h 3•'r+':'sJi.'!' _ <br /> F blame s L'?il�r7/d `� y �e7 <br /> liar:eS� L t c j "�li-j-- vee/.. (fig✓ -� + <br /> rss3r Name:Site Address: <br /> Street Address <br /> Phone: CZC <br /> It tete commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my= <br /> M-smry a4 checked below: <br /> E gush v�ashing sink <br /> solid v��aste dispose. �Store frozen faces i �Ieh- ide vras4�facilities z <br /> (2 ora cor�+4rwrt�) <br /> food of&Cold water for cleaning t�hand washing 0 Store rated focd <br /> foodls=jpplies Vide 'stable water vemight parking �Fadeq�ate ele.^trica outlets <br /> re of COwner/Operator Date <br /> _ ONE x# _a <br /> If the commissary/food establishment is outside San.ioaquin County,the local`ealthjurisdiction MUM!ve! <br /> "Urr_a ft health permit by signing below. Commissaryffood establishment is in <br /> County <br /> Signature of County RENS Date - <br /> 5 o;6 MFPU APPMAMN <br /> oto ts-of <br /> ��a�ss <br />