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VERIFICATION OF VEHICLE COMMSSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> 11 Is OR I Ill.— <br /> Vehicle Name (DBA): 5 L <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate* Dh 52- 9 U � 4) Year: [�v� S <br /> 2) Vehicle Vin* l Make/Model: <br /> 3) State Decal #: 6) Color: <br /> 1:1%E sr - <br /> Name: P.9 <br /> Address of Owner: - b <br /> streefAddress 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 may result in permit revocation and penalties. <br /> i'WC iG p 1 /,,oro /20 l t <br /> S�iqrrature of Vehicle Operator D e <br /> WN <br /> Ca of o <br /> Business Name: L-1 <br /> Owner Name: �V <br /> Site Address: I <br /> treet Address � I � City <br /> Phone: 1-0_� <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 /> "uid olid waste disposal Store froznUtensil washing sink e food ehicle wash facilities <br /> 2 or 3 compartments) ❑VPr;aration of food VHVPr9W4 <br /> cold water for cleaning �vemi&Qht <br /> and washing ❑ S re refrigerated food <br /> re dry foo upplies e`npotable <br /> 'water park i g Adequate electrical outlets <br /> 1h, W" 04 <br /> S nature of Commissary Owner/ perator Date <br /> ifs � - <br /> If the commissarylfood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br />