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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ' L:.._. � i.-...... �-,c='> --E'..`4c.,/�'=:>.!Y ';.n.L e$4rsr ��.':.f4_eslar,'Yr!-+.Y.j•- a2:..��P. _�f' ���,t`�-"- '�� - <br /> Vehicle Name(DBA): -r r-_-_ c' 17c <br /> Address for Vehicle:. <br /> street Address City <br /> 1) License Plate#: d C 4) Year: C1\C�eA <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal-#: 6) Color: <br /> NErBROWN <br /> Name: - <br /> Address of Owner: �= 'i 0 Z �✓ �� <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&'t,14297). 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 /> Si nature of Vehicle O erator Date <br /> .. ,,��..�-.. <br /> r � •� -�_ �... ���- � ��a.�:. ?x=.rc_ ice. <br /> !lf)iSSfiE ORN1Afi�( Y <br /> - <br /> Business Name: Q') i c< < <br /> Owner Name: ? , ; <br /> Site Address: <br /> Street Address city <br /> Phone:.(Sj�,q) GI <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 /> ❑ Li uid&solid waste disposal Utensil washing sink ❑Store frozen food Vehicle wash facilities <br /> 4 (2 or 3 compartments) <br /> Q Preparation of faod ❑Hot&cold water for cleaning Toilet&hand washing �� Store refrigerated food <br /> ❑Store dry food/supplies . ❑Provide potable water — Overnight parking �.Adequate electrical outlets <br /> signature of Commissary Owner/Operator _ Date <br /> C/#1TF7��, '- � ;'y?z-=-�:- - <br /> .a=,-(-�_.,-moi..--c�_ :<M _ _ -�i'�:a.�-�_h� _ -�' -�'-`'.-�r'�•'r-M";:-If the commissary/food establishment is outside San Joaquin County,the local health-jurlsdiction must verify <br /> current health permit by signing below. Commissary/food establishment Is in <br /> County. <br /> Signature of County RE HS Date <br /> EHD 16-017 5 of 6 - WPU APPLICATION <br /> 7/18/2008 <br />