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VERIFUCATOOM OF VEHOCLE COMMMARY <br /> Please Provide all inforatation requested. An incomplete application may delay approval. <br /> Vehicle Name(DBA); <br /> Address for Vehicle: <br /> If Street Address <br /> Ucense Plate II/1,40S7 4) Year. <br /> 2) Vehicle Vin tP- 6) Make/Alodel: <br /> 3) State Decal P <br /> 6) Color <br /> -TION, <br /> Name: <br /> -0 <br /> Address of Owner. <br /> SfrMAddiew 75 <br /> he mobile 7bod facility shall 010OFats Out Of 2 COMIT11852W and shall report to the corrinftsary at least once <br /> i OROM64ing day for Gleaning and servicing (Ga[Gado Qocaons 114295& 98 297). ea <br /> If the use of the Gaminiew ry is I <br /> discontinued, the Permit holder mum rjOtMj this Office W make 2ha necessary - wig <br /> changes. Fa I-lure to notifij t <br /> mrTme may result in permit revoca4-on and Penalties. <br /> i6cure of Vehicle Opqraf6r <br /> Business Name: <br /> Owner Nam <br /> R. C <br /> Site Address: q00 �'on C-A q <br /> hs <br /> SbvatAddress <br /> Phone:(ZC!, <br /> (0�A- <br /> 19 COMMissary owner,can and MCIR provide ihe necessary facilities for the above mengoned <br /> vehicle at-,IV <br /> COMMISsenj as checked beiour <br /> Liquid&solid waste disposal Utensil washing S-Mk <br /> (2 ors compactmems) *,, []Stare frozen food Vehicle wash facilities <br /> El Preparation of food Hot&cold water for clearaM Toilet&hand washing Store refrigerated food <br /> i <br /> Pfo'ndq potable wa�r <br /> ❑Store dry food/supplies Roifide potable waier <br /> sup s Overilight parldng <br /> Ade uate electrical outlets <br /> t C)o <br /> Llre O� <br /> I rat <br /> '00M <br /> Signature of Missa <br /> �Owne�_pera <br /> pera Date <br /> DEPARTMENT- <br /> ff the carnmisseqM00d establishment is outside San Joaquin County,the local <br /> heaM jurbaficdon must verify <br /> health permit by signing below_ COMEWL*_ <br /> ,Myjfood es lishn rr� <br /> el tab je is n <br /> Signature of Countf RENS <br /> Date <br />