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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): - YC i I � <br /> Address for Vehicle: ., /JJ� ❑ _ ' <br /> Street Address City <br /> 1) License Plate#: �. J�, j 4) Year: <br /> 2} Vehicle Vin#: 5_3 I16 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE 01nER INFORMATION 2 <br /> Name: <br /> Address of Owner: <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 perm and penalties. <br /> l� 4�6 % <br /> ehicle Operator Date <br /> ROMi�—R'SAINFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: — � C d' <br /> c c 1' <br /> Street Address City <br /> Phone: (tit C` l1 C <br /> f,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> Liquid 4&-solid waste disposal alltensil washing sink ❑Store frozen food icle wash facilities <br /> ( mpaeanents) <br /> ! Preparation of food Hot& ter for leaning oilet&hand.washing ❑ Store refrigerated food <br /> "7toreodlsupplies Provide potable water vemight parking DA<uate electrical outem <br /> Signature of Commissa 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 RENS Date <br /> FUR 9Ci1�7 _.,ac aicai naa>>r-n-.�>i <br />