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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): 6c=3 <br /> Address for Vehicle: 51 <br /> treat Adtlress city <br /> 1) License Plate#: 4/h/f 9 `Ili 4) Year: 20 U <br /> 2) Vehicle Vin#:/P-? /oZo"L3G4/3S�Oa(0 5) Make/Model: L <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION — <br /> Name: I P� ce5 <br /> Address of Owner: l g 3 d (_I ve pfog <br /> Street Address , c(ty <br /> The mobile food facility shalt 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 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 /> kOMnature of ehicle Operator Date <br /> MISSARY INFORMATIOIJ <br /> Business Name: <br /> Owner Name: <br /> Site Address: v <br /> Street Address city <br /> Phone: �El <br /> t,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> tensa washing sink&solid waste disposal <br /> El Store frozen foodehicle wash facilifies <br /> (2 or 3 compartments) <br /> Prepa n of food of&cold water for cleaningdet&hand washing Store refrigerated food <br /> Store food/supplies vide potable wa vemight parkingequate electrical outlets <br /> l _ <br /> S' nature of Commissa caner/O erator Date <br /> HEALTH DEPARTMENT <br /> If the commissay/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 />