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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: <br /> treat Address City <br /> 1) License Plate#: 1-1L7/41.9 v;r-? 4) Year: SOU <br /> 2) Vehicle Vin#:/f-yIIu/ot,"tY3G�3So0 5) Make/Model: / L <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION —7 <br /> Name: <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 (CaiCode 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 /> Nnature of ehicle Operator Date <br /> COMMISSARY INFORMATIO <br /> Business Name: <br /> Owner Name: <br /> Site Address: % <br /> Street Address City <br /> Phone: �� /� <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 /> quid&solid waste disposal tensil washing sink <br /> (2 or 3 compartments) ❑Store frozen foodehide­wash <br /> Prepawen of food of&cold water for cleaningdet&hand washing El Store refrigerated food <br /> Store food/supplies vide potable watvemight parking equate electical outlets <br /> Signature of Commissa wner/O erator 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 />