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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): T G Co.S rJ <br /> Address for Vehicle: 730 , 8 <br /> Street Address city <br /> 1) License Plate#: ,5� 9�74 1 4 Year: 7 f�� <br /> 2) Vehicle Vin#: 1 / Make/Model: PZe!:!!Z <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION 2C� <br /> Name: e <br /> Address of Owner: S <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 /> o . ay result in permit revocation and penalties.- ) I Cj**VLZ-6 V�4 M4=0,Al :3 <br /> l� 7 <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATI N <br /> Business Name: <br /> Owner Name: <br /> Site Address: &—> <br /> Street Address city <br /> Phone: ( l 7! <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 /> squid&solid waste disposal ensil washing sink ❑ Store frozen food eNde wash facilities <br /> (2 or 3 compartments) <br /> reparation of food Hot&cold water for cleaning F4 ef&hand washing ❑ Store refrigerated food <br /> D-Ko dry food/supplies id <br /> ve potable water ern�arking equate electrical outlets <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin Cr <br /> current health permit by signing below. Commissary/food estak SAN JOAQUINCOUNTY <br /> County. ENVIRONMENTAL HEALTH <br /> FOOD VEHICLE PERMIT <br /> Signature of County REHS Dat - <br /> EHD 16-017 5 of 6 <br /> 7/18/2008 44- 8 <br />