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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): e� ('�Y(,2 (-e1 D & O <br /> Address for Vehicle: "736 S Ls s kckln <br /> Street Address City <br /> 1) License Plate#: 6g=�_5��� 4) Year: <br /> 2} VehicleVin#7 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OVVNER INFORMATION <br /> Dame: '� , <br /> Address of Owner: 52C • , <br /> Street Address city <br /> The mobile food facility shall operate out of a cflmmissary 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 i perm n and penalties. <br /> 1� <br /> e- ehicle Operator Date <br /> rC0MZ* 1S1`SARY INFORMATIPN <br /> Business Name: <br /> L L Lr e-v .&L-_& <br /> fir <br /> Owner Name: <br /> Site Address: <br /> Street Address city <br /> Phone: <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 /> t.i uid&solid waste disposalUtensil washing sink sh facilities <br /> t2 or mpa�enrs? Store frozen food <br /> Preparation of food Hot ter for Leaning oifet hand washing Store refrigerated food <br /> tore odlsupplies Provide potable waterj�6vemight parking equate electrical outets <br /> Signature of Commissa Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> tf the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissarylfood establishment is in <br /> County. <br /> Signature of County.REHS Date <br />