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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): 99 v <br /> Address for Vehicle: Ste' <br /> Street Address City <br /> 1} License Plate#: � 4) Year: %y <br /> 2) Vehicle Vin #: /S1 aWq 16- Make/Model: e <br /> 3) State Decal#: 6) Color: /Z GY P <br /> VEHICLE OWNER INFORMATION anooclqcl 2LI <br /> Name: k6'-T4A �• vtl�Pcl by <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 <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, the It holder must notify this office to make the necessary changes. Failure to notify this - <br /> offi a may re ult 1 ( it evocation and penalties. <br /> (L(p Tri 9 rq-L--z m <br /> Signature of cle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: l/ <br /> Site Address: r 9S�o <br /> Street Address City <br /> Phone: (;&9F ® <br /> I,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> quid&solid waste disposal tensil washing sink Store frozen food &W Isle wash facilities <br /> (2 or 3 compartments) <br /> ;t�e <br /> ara' n of food of&cold water for cleaning oilet&hand washing ❑ Store refrigerated food <br /> ry food/supplies rovide potable water ernight parking equate electrical outlets <br /> i nature of Commissary Owner/Operator Date <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. Commissary/food establishment is in <br /> County. <br /> Signature of County.REHS Date <br /> E-- 16^077 6of6 WPLIAPPLICATION <br />