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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): �"Ct C �� 67 <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: 4) Year: <br /> 2 Ve I V <br /> h!c e . In # C���3 ,��3�7/�S 5) Make/Model: C � <br /> 3) State Decal #: 6) Color: P <br /> VEHICLE OWNER INFORI4'IATION — <br /> Name: l I z— �L 1. <br /> Address of Owner: J 11_._S, t� �� 164 <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. J <br /> 6dC4%"Y-i�) v,71A.I",zm <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATIO <br /> Business Name_ 6tC (tea <br /> Owner Name: Q <br /> Site Address: - — -- — <br /> Street Address city <br /> Phone: _ Zd 7l 1 1 � <br /> i,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> ;Liclu:idsolid <br /> miss as checked below: <br /> waste dis osal Utensil washing sinkp (2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> Prepon of food of& !d water for cleaning Toilet& washing ❑ Store refrigerated food <br /> Stor od/suppli s Provide otabl water Overni htparking electrical ut!a` <br /> �Pa _e',s <br /> 9 �_A�dequate <br /> Signature of Commissary Owner/Operator 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. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> �Ltll c.nt: _,cc uca ..cn, inn rims <br />