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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): <br /> Address for Vehicle: < C/Gr S' SAO <br /> Street address city <br /> 1) License Plate#: ! f� 630 0 4) Year: �QO� <br /> 21 Vehicle vin #: /v�jS5) Make/Model: CrG <br /> 3) State Decal#: 6) Color.- <br /> VEHICLE <br /> olor:VEHICLE OWNER INFORMATION 14 <br /> Name: /ZUcS UC,c 1 vt/l P <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 I <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 permit revocation and penalties. <br /> Sw ature of Vehicle O erator Date I <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: 5-�' Ir� :y5� <br /> Street Address City <br /> Phone: (2 eZ� <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 /> iquid&solid waste disposal t—i Utensil washing sink <br /> m���,rst Store frozen food ehiGe wash facilities <br /> {s o �o / <br /> repar n of food Hot& d water for cleaning �f ollet&h washing ❑ Stare refri rated food <br /> Sto foodlsu lies rovide potable water I��,,,E� rni ht parking Adequate electrical aut!�fs <br /> rY PP P 9 P 9 q c <br /> Signature of Commissary Owner/Operator D to e <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. Commissarylfood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> can 1a-n» <br />