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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide ail information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicie vin#: yT//_3 /F/<! /r g&,3 715) Make/Model: 7l> l <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: 9:34 __ t, 551 <br /> Address of Owner: 'S4G <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 (CaiCode sections 114295 &r 114297). 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—r7kstdt in permit revocation and penalties. <br /> Suture of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: 7,30 � G <br /> Street Address city <br /> Phone: (Z ) j zU �j j <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 /> ® it quid&solid waste disposal tensil washing sink F1 Store frozen food Vehicle wash facilities <br /> (2 ora eompartnents) <br /> Preparation of food EAAot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> Stor ry food/supplies rovide potable water vemight parking Adequate electrical outlets <br /> Si nature 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. Commissary/food establishment is in <br /> County. <br />