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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incornpWa application may delay approvai. <br /> Not I-W <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> 17 <br /> Street Address-- City <br /> 1) License Plate#: q(59Z-12 S 1 - 4) Year: <br /> 2y� Vehicle Vin#:Jr-,12 <br /> q MakelModel: -W ( <br /> 3) State Decal#: 6) Color 'e <br /> 7- <br /> AMINO WOWN 01 "Ot <br /> Name: Lc).Po—Z <br /> (�7 <br /> Ad-dress of Owner: CJLL� 9521 V <br /> Stivet Address c-'t, <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 (Ca:]Code sections 114298 & 114297). If the use of the commissary Is <br /> d-1 d the permit holder 194�(St notjfy this office to make the necessary cbangess. Failure to notify this <br /> o;CC'eDn-tZU`r'-;Ul I Pe !t re7o 'w4on and penalties. <br /> 'SignatCer o-�44fiidebpera W Date <br /> 9, <br /> .MV ,=5 <br /> Business Name: <br /> Owner Name: a <br /> Site Address: 13-�f D <br /> Stmt Address CAY <br /> Phone: <br /> L the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> M,6-q�uid a solid waste disposal 916t-�Sll washing sink 0 Store frozen food ehicl2 wash facilities <br /> (2 or 3 compartments) <br /> E ,epar food 0,,416-t­&—cold water for cleaning Z-T0,�e-&hand washing E, Store refrigerated food <br /> ,�:Wrrx;�-rabb n of <br /> .7� dr -7t��e i-at ouftlets <br /> S t�70pod foodisupplies 24-fovVide potable water F,/Overftht parking equate electri <br /> dry <br /> i Inature of Commissary Owner/Operator Date <br /> if the co3pmIssary/food establishment is outside San Joaquin County,the local health jurisdiction must verity <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County RENS Date <br /> 1=9-1[316-017 5 of 6 MFPU APPLICATIO'.14 <br /> 7il MPUP-0 <br />