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VERIFICATION OF VEHICLE COMMMSARY <br /> Please provide all information requested. An incomplete application arty deiay APP-.3vs= <br /> veNde Name(DBA): 7-1-le � l r C-- -5 --- --�— - <br /> Add resa fx Vetkle: 736;) 75L -- <br /> sa•ec Aaatr�a C" <br /> G C — --- <br /> 1) License Pia*W, ��g11 �� 4) Year. <br /> 2) VetNcie vin 1(; �p3 a kq 3 01`77� Maketfvladei: <br /> 3) State Decal : <br /> I Wei OW, <br /> - -- - - <br /> Addrem vf©wnsr: 7 , C,Ll C <br /> . ----- <br /> Cft <br /> a <br /> The mobile food faGMY shall operate out of a cofnmissary and shell report to the commissary at least otsce sech <br /> oeeratting day for cleaning and servicing (CalCode sections 114295 & 114297). if the use of the commissary is <br /> is <br /> discopti+nued, the permit holder frust notify this office to make the nee:essery changes. Failure to notey € <br /> offtl�riay resu . in permit revocation and penalties. � <br /> 3 <br /> Of Vehicle Q <br /> jwatpr ---- Date - <br /> hour,Name: _ --- <br /> Site mess: _ � <br /> tz the coram mmy�owter,can and wit provide the nett swY f8ciifties for th&at:ov metztion$d vrahicke at any <br /> comnissary as checked below: <br /> r b <br /> ( t i2Bf 5+! s2�i af:y swe lfotefi tOGU L'7:2L7S IIOZ y faV tt"-" <br /> Solid W38tC i AQ.S:ZI (3 or 3 coff4mrinawnft) <br /> �, ash [' Stores food <br /> r �r,of c i +fit L�cxxa�d crater frr cleaning [L}-t id`N ..- s <br /> ' a OVW—i�6gtii parking u�te e#eetrti�,at o tWs Y <br /> �c�ts+�table�dt6t !_ �e�' "„ <br /> rT <br /> �NHT'N LEPATine commissarygood establishment is outside San .loaquin County,the iocal health jurisdi'rtion must Vere d <br /> cwmni.health perw4t by signing below. Commissary/food establishment is in <br /> County. _- <br /> County. � <br /> 1 <br /> Signature of County RENS ate <br /> £r, '. j- <br /> MFPt1 APPt iCATiOW <br /> rt x rix} <br />