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l <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> beet Address City <br /> 1) License Plate#: 6-U(V A 3 3 J 4) Year: z9cop <br /> 2) Vehicle Vin#eFAL 3s;L13�/3 5) Makelmodei: eLj <br /> 3) State Decal#: 6) Color: <br /> -- - <br /> Name: G C7 Y t w- ZZ <br /> Address of Owner: <br /> StreetAdkhessrAty <br /> The mobile foot 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 holderst notify this office to make the necessary changes. Failure to notify this <br /> office may result in pe revoca o and nalties. <br /> Slanatureof Vehicle Operatof Date <br /> Business Name: <br /> Owner Name; <br /> Site Address: p� <br /> --- - y <br /> -Address taw <br /> Phone:(Z OC.2 V9) 2 ZZ ZIKI <br /> O:the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as•checked below: <br /> $soft Waste disposal g"""'"washing th* ®Store frozen food 42—V&clevash iaciiiGes <br /> ,—,� ff ora rA,t�armreeui <br /> I r3Preparation of food R goft 4cold water for Weaning �oifet8 hand washing �� _-sttore refigerated food <br /> y fooWsupplies R rrnvwe pmwe water fight parking rot's L-Wo ricafou9ets <br /> _attireo Commissa Ownerl <br /> 6 _ <br /> N the comrft"iylfoed establishment is outside San Joailiiin 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 REH5 Date <br /> so 16017 5 MB MFPl1 APPLICATION <br /> 711811008 <br />