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VENICLE INFORMATION <br /> Vehicle Name "DBA : �` <br /> (DBA): <br /> .y i <br /> Address for Vehicle: _3�� Y <br /> StreetAddress � �%C � t� <br /> City <br /> 1) License Plate#: 4) Year: rZ <br /> 2) Vehicle vin#: L''PL 3-93..3;-7/`;�j 5) Make/Model. <br /> 3) State Decal#: 6) Color: 1-7 <br /> VEHICLE OWNER INFORMATION <br /> G G ! <br /> Name: <br /> Address of Owner: �G; <br /> street pddrgss <br /> 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 & 194297). 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 /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATIO <br /> Business Name: <br /> Owner Name: <br /> Site Address: /? <br /> stmt Address <br /> Phone: 9! CI�S3 <br /> _U ctty <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> ff-Liquid&solid waste disposal ensd washing sink <br /> (2 or 3 cOavarhnenta) ❑Store frozen food ehicle wash facilities <br /> reparation of food ErHot&cold water for cleaning f�fi <br /> olet& <br /> J�J � hand washing L j Store refrigerated food <br /> or food/supplies rovide potable water � //' <br /> r' <br /> ElOvemight parking dequate electrical outlets <br /> ;nature of Commissa Owner/0 erator Date r <br /> HEALTH DEPARTMENT <br /> if the commissaryffood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissarytfood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> r-wn 12n17 <br /> necni zona ern r.�a <br />