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VERIFICATION OF VEHICLE COMMISSARY <br />VEHICLE INFORMATION: <br />Vehicle DBA: 1 a c, ci (.7( paliCk <br />Address listed for Vehicle: 7111. C(i CGCl /CLt) <br />License Plate#: G 6 6gI1.2 Veh. ID#: IFDuiR6P39E854)6State Decal#: <br />s -/ to ci- (q ,( <br />Year:0 01-i Make: FOP D Model: 35C Color: Whale <br />VEHICLE OWNER INFORMATION: <br />Name: Sa V ad oNi \Jaye, I a.. CDL#: F-61)51-( 6 s <br />Address: 9112_ y 0 CA) City: (0 cif' Zip Code:75-2 Vo <br />THE ABOVE MENTIONED VEHICLE SHALL OPERATE OUT OF A COMMISSARY AND SHALL REPORT TO <br />THE COMMISSARY AT LEAST ONCE EACH OPERATING DAY FOR CLEANING AND SERVICING [CURFFL <br />114265 & 114231]. IF THE USE OF THE COMMISSARY IS DISCONTINUED THE PERMIT-HOLDER MUST <br />NOTIFY THIS OFFICE TO MAKE THE NECESSARY CHANGES. FAILURE TO NOTIFY THIS OFFICE WILL <br />INVALIDATE PERMIT AND IS SUBJECT TO PENALTIES. <br /> <br />Air <br /> <br />- <br /> <br />SIGNATURE OF VEHICLE OPERATOR DATE <br />COMMISSARY INFORMATION: <br />Business Name:16-41 Pit S.c cy, k-1 /4-‘ u 1Pe,ci <br /> <br />Owner's Name: A' ce 6 ca C 4- 0 <br /> <br />Site Address: 73 5' c; P4-CY ,e-P ;4,40 City: <br />Phone Number: ( 2-0 q' ) 7 57 -7 <br /> <br />)_'c cL <br /> <br />Zip Code: -2- 6 <br /> <br />Etc sas, <br /> <br />I, THE COMMISSARY OWNER, CAN AND WILL PROVIDE THE NECESSARY FACILITIES FOR THE ABOVE <br />MENTIONED VEHICLE AT MY COMMISSARY AS CHECKED BELOW: <br />0 Preparation of food 0 Store Frozen Food O Store Refrigerated Food <br />0 Electrical Hook-up 0 Store Dry Food ID Store Supplies <br />0 Toilet & Handwashing 0 Overnight parking 0 Supply Food Products <br /> <br />DATE SIGNATURE OF COMMISSARY OWNER/OPERATOR <br />HEALTH DEPARTMENT: <br />IF THE COMMISSARY/FOOD ESTABLISHMENT IS OUTSIDE SAN JOAQUIN COUNTY, THE LOCAL <br />HEALTH JURISDICTION SHALL VERIFY CURRENT HEALTH PERMIT BY SIGNING BELOW. FOOD <br />ESTABLISHMENT/COMMISSARY IS IN COUNTY. <br />SIGNATURE OF COUNTY REHS <br />EHD 16-01-017 <br />12-19-01 <br />DATE