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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide ail information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name(DBA): <br /> Address for Vehicle: 4 <br /> Street Address city <br /> 1) License Plate* �� L 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: C7 y1i/ <br /> 3) State Decal#: 6) Color.- <br /> (� <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: <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 (CalCode 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 may result in permit revocation and penalties. <br /> Sonature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: �r <br /> Owner Name: <br /> Site Address: <br /> Street address city <br /> Phone: e 2 7Z1 7 <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 /> liquid&solid waste disposal nsil washing sink �ore food ehide wash facilities <br /> 12 or 3 comparrmeats) <br /> Prepara-ho of&w r for deaning hand washing ore refrigerated food <br /> for food/supplies Provide potable water D,9emit ght paridng " dequate electrical out'ets <br /> S" nature of Commissary Owner/O erator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food 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 /> C mss/ yr <br /> Signature of County REHS Date <br /> GUR sR11a7 c.fr a:rnvnaw rw rn. <br />