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VER1FIATION OF VEHICLE COSMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: 5-D 0 4) Year: <br /> 2) Vehicle Vin#: l UD 4 P3R K!4l;?35RDl-7715) Make/Model. <br /> 3) State Decal* G) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: CJ 19ce <br /> Address of Owner: C) S7Sa <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 114295 & 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 ay res n ermit revocation and penalties. <br /> Agrikure of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 1 /,4 4 <br /> Owner Name: <br /> Site Address: 3 y)1 <br /> Street Address city <br /> Phone: (Z ) to c) l 2o'1 7 / <br /> f.the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> iruwa,solid waste disposal au�tensil washing sink <br /> (2 or s compartments) V Store frozen food Vehic3e wash facilities <br /> Preparation of food Not&cold water for cleaning oilet&hand washing ❑ Store refrigerated food <br /> tore food/suppiies rovide potable water Overnight parkingAdequate electrical outlets <br /> signature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissaryffood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissaryffood establishment is in <br /> County. <br /> Signature of County REHS Date <br />