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VERIFICATALON OF VEHICLE CO� IISSARY <br /> . I <br /> Please pr6v6de .Al inform,W requested. An incomplete applica may delay approval. <br /> Z's'l;,"N-�MZAM IBM=®R WWWREREW 511% <br /> Vehicle Name (DBA): <br /> Address for Vehicle: a,2 <br /> -77 , <br /> Street Address City Zip <br /> I) License Plate M 4)* Year: 0Z <br /> 2) Vehicle Vin fl: 5) Make/'Model: pe c�S <br /> 3) State Decal 9: 6) Color: <br /> Mt".'4 1 r% <br /> Name: <br /> Address of <br /> Street Address ---City 7ip <br /> The mobile food facility shall operate out of a commissary and shall ireport to the commissary at least <br /> once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of <br /> the commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br /> Fa e to notify this office may result in permit revocation and penalties. <br /> SihVlISf Vthlie)e 0 <br /> O—Iliie'1,'1�r7:ga4ttYvo7;rrya1 <br /> Date <br /> 12t <br /> NO M� <br /> Business Name: e <br /> Owner Name: <br /> Site Address: C <br /> Street Address City 7ip <br /> Pholle:02Tzi�? , <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at <br /> in), commissary as checked below: <br /> Liquid 8-,solid waste Utensil washing sink E] Store frozen foodVehicle wash facilities <br /> d'sposal (2 or 3 compartments) �1) <br /> F] Preparation of food �llot&cold water for cleaning � Toilet&hand washing Store refrigerated food <br /> Store fb /Supplies rovide potable water Overnight parking Adequate electrical outlets <br /> Signature of Conunissary Owner/Operator Date <br /> QN, <br /> A,A - 6 <br /> If the conunissary/food establishment is outside San Joaquin Count),, the local health jurisdiction must <br /> verify current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County R.E.H.S. Date <br /> BID 16-013 Page 8 of 9 MFF APPLICATION <br /> 8/17/2007 <br />