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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> E ttc lav�+o !a rioi r <br /> Vehicle Name (DBA): DAIAIG E <br /> Address for Vehicle: L-5 D 1 It, C. <br /> street Address ' f Cay <br /> 1) License Plate* 4) Year: _ <br /> 2) Vehicle vin#: /3 }9 1^ �gDatpjModel: 11 <br /> 3) State Decal* 6) Color: <br /> X Nil <br /> Name: V - Y t I f <br /> Address of Ow r: C) C O G O <br /> ' Street Address Cly <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 leaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary Is <br /> disco nued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> - <br /> office,_ ay result in permit revocation and penalties. <br /> 15;1/9// <br /> Si n r of Vehicle Operator Date 0 <br /> x� renes <br /> riO_ SSA �NFIRIVI�TIO <br /> Business Name: ✓1 <br /> Owner Name: <br /> Site Address: (0 r <br /> street Address cfty <br /> Phone: 0 12 yj <br /> l <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 /> 0-6�quid&solid waste disposal U'""'nsil washing sink ❑Store frozen food ehide wash fadii6es <br /> (2 or 9 comyarbasi . <br /> repa - -of food of& Id water for deaning oilet&hand washing ❑ Store refrigerated food <br /> for food/supplies rovide potable water emight parking uate dedncal outlets <br /> nature of Contrill C erator Date , <br /> � 'r., 'l2TIN N <br /> fEthe commissary/food establishment is outside San Joaquin County,the locatttealth Jurisdiction must verify <br /> current health permit by signing eti Commissarylfood establishment is In <br /> County. <br /> Signature of County REHS Date <br /> EHU 16-017 5 of 6 MFPU APPLICATION <br /> 7116f2006 <br />