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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(DSA): ISO S` <br /> Address for Vehicle: <br /> treat address city <br /> 1) License Plate#: 4'ED51--5- 4) Year: Rr <br /> 2) Vehicle Vin#:+Z6LNI0Uo FQODU 5) Make/Model: f�X¢ IATIL- <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: A nt <br /> Address of wner: gaton <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 iii 1142971. 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 /> 1 / <br /> IC- <br /> -Signaturd of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> 4 <br /> Street Address city <br /> Phone: <br /> Ze <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 /> uid lid waste disposal tl washing sink <br /> q poses ❑Store frozen food ehicle wash facilities <br /> {2 ar 3 compartmenEs) <br /> Vi <br /> reparation of food of a cold water for cleaning � - &hand washing ❑ Store refrigerated food <br /> 00o dry supplies rowde potable wateright parking quate electrical outlets <br /> Signature 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. Commissarylfood establishment is in <br /> County. <br /> Signature of County REHS Date <br />