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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />NOT .- 'n <br />Vehicle Name (DBA): <br />Address for Vehicle: <br />street Address City Zip Code <br />1) License Plate #: 36 d= h1' C a6 4) Year: 1977 <br />2) Vehicle Vin#:C /AL3 5) Make/Model: CPIGtV — V/1% <br />3) State Decal #: 6) Color: (Jr� <br />s 4 p <br />Address of Owner: J—j2/ <br />street Address 20f �2 City Zip Code <br />The above-mentioned vehicle shall operate out of a commissary and shall report to the commissary at <br />least once each operating day for cleaning and servicing [CURFFL-144265 & 114287]. If the use of the <br />commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br />Failure to notify this office could result in permit revocation and penalties. <br />SOSe .Q )PClfS CA�7nIt�7 7-9 <br />Signature of Vehicle O erator Date <br />IN X1,9111 =111 <br />�uBusiness Name: <br />Owner Name: — <br />Site Address: qJ <br />st 1Addreas City Zip Code <br />Phone: (p&1=4r:� M <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle <br />at my commissary as checked below: <br />Xr <br />Liquid & Solid waste disposal Utensil washing sink Store Frozen Food Provide ice <br />Preparation of Food Electrical Hook-up IT, <br />Toilet & Hand washing Vehicle Wash Facilities <br />ERSlore Dry Food/Supplies Provide potable water &Overnight Parking Store Refrigerated Food <br />7- q-0 C' <br />Sin Lure of co ss Owner/O erator Date <br />If the commissary/Food establishment is outside San Joaquin County, the local health jurisdiction <br />shall verify current health permit by signing below. Food establishment/commissary is in <br />County. <br />Signature of County R.E.H.S. Date <br />EIID 16-017 Page 5 of 6 MFPU APPLICATION <br />9/4/2006 <br />iNG <br />RVICE <br />r7A <br />