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VEHICLE INFORMATION <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> street Address Ge <br /> City <br /> 1) License Plate#: � � a g �j 4) Year: ; 7 <br /> 2) Vehicle Vin#:Cp1t3��3 / S 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Mame: 2 <br /> Address of Owner: '30 i& <br /> street Address <br /> citjr <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating day fear cleaning and servicing [CalCode sections 114295& 114257). If the use of the comrrtissary is <br /> dlscontin ed, t Kermit holder must notify alis office to make the necessary changes. Failure to notify this <br /> ofR res n permit revocation and penalties. <br /> n o ehicie nrutrator <br /> COiMMISSARY INFORMATION Date <br /> Business Name: 11 /- <br /> Owner Name: LG <br /> u <br /> Sllte Address: <br /> stnaet Add�ass <br /> Phone: (Z' OCAY <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 /> L�L� slid waste disposal Utensil washing sink <br /> tz or 3 co-12-13-nfai ❑Store en food ehide wash tadGties <br /> Pr on Of food of& water for clewing Toilet&hand washing [] Store refrigerated food <br /> S dry foodl ►es Provide <br /> Potable water6uemight parking dequate efectrical ouvets <br /> S' nature of COmmissa Qwner/0 erator <br /> HEALTH DEPARTMENT Date <br /> If the commissaryfi;ood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> curfent health permit by signing below. Commissaryffood establishment is In <br /> County. <br /> Signature Of County.REHS Date <br /> "n 1"17 <br /> �r <br /> uCD! 1!1111 11+a T1A>, <br />