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VEPUF1C,,AT10N OF VEHICLE-` COMMISSARY <br /> ,11­35E! ptovide a11orrn? Minits 97.ia tei-t, An incnrnrik=tc! -application mav ri-einy apppr<w-! <br /> VEHICLE INFORMATION <br /> Vehicle Namie ;DB, )- <br /> --tcy-V - <br /> Address ;or Vehicle: VY0 <br /> 5�0Cklpn C-fi 7 5 2-0,C <br /> Str9st Address <br /> 1: License Plate # 0 0 <br /> 2'J Vehicle Win 1: <br /> k-6-K 500-5)46 <br /> 3, State Seca! 4'�. <br /> VEHICLE OWNER INFORMATION <br /> ,N <br /> V <br /> Address of Owner <br /> Street Address Y <br /> The Mobi!P foodfaCility Shall operate out of a. commissary and stiaN reportl,t:) 1c cc.-mmissary at least once eac"11 <br /> ift"-.eLiSeofthe COMri!ssarvls . <br /> dis-ontinued, the per-mit holler r-nust notifl., thi-­ offica U make tl'e npcessain/ changes. Failure to notffv this <br /> office may result in permit revocation ard fienalties, <br /> Signature of Vehic-ie Opera to;­ On C( a-d-P Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Addres- 21 c <br /> Street Address cite <br /> -Phone: ( <br /> 1, the commissary -owner, can and will provide-1-hq necassary facilities f1c.'r the above mentioned vehicle a� rn, ,, <br /> is� <br /> - d below: <br /> c o M mn s a ry a s checker! <br /> ;Cle WaSh <br /> ink. te�'�ispr'321 lc�nl<1 I e r,s wa-,h n o r'. Fay' i <br /> Sc!i,4 (2 or: er, <br /> C, :c•l,� !:zter n c c,e rerrige—err <br /> Signature'of Com—mis7sary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the cornmissary/food estabUshment is outside San Joaqu;n County. the local health iurisdictiorl must Verify <br /> current health permit by Signing below. Corrnnriissary!fond establishmient, IS iii <br /> County. <br /> SignatUre of Coi,.inty REHS Date <br /> E HD 16-0 17 <br /> "IMC, <br /> -03 <br />