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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay Apprbvat: <br /> Vehicle Name(DHA):+u4 <br /> Address for Vehicle <br /> street Address city <br /> 1) License Plate#, Z/ 4) �[[Year: <br /> 2) Vefsde Vin#: L /MakelModel: C ,v <br /> 3) State Decal#: 6) Color- <br /> Name.- <br /> Address <br /> olor:Name.- <br /> Address of Owner: <br /> taaaress <br /> CRY <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(CatCode sections 114295 S 114257). If the use of the commissary Is <br /> discontinued' the permit holder rm im notify this office to make the necessary changes. failure to notify this <br /> office may resuk in permit revocation and penalties. <br /> S re of Vehicle Date <br /> Business Name. �' '' <br /> Olnfner Name: <br /> Site Address: l U <br /> - - - – – <br /> SLesAddress CRY <br /> Phone: Ca(" / /75(d <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 /> T <br /> li d&sm Waste t ispmai Q5<lGmil washing sink ❑Store frozen food myeNcie wash facilities <br /> / (2 m a conVaitmota) <br /> 015reparation of food 01lo—M cold water for Cleaning oilet&band washing Store refrigerated food <br /> dry foodfsWPResjo� vide pohable water ven ght parking equate electrical outlets <br /> -- <br /> e U ! <br /> S of Citi tom Date <br /> If the coinudiitarylfobd establishment is uiitside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissaryffood establishment is In <br /> County. <br /> Signature of County RENS Plate <br /> gm 1"17 5of-6 tAFPN APPLICATION <br /> 7/98/ 108 <br /> �� boal�yy <br />