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Vehicle Name(DBA): <br /> Address for Vehicle: <br /> Street Addn'ss _ <br /> EAY <br /> �) License Plate#: <br /> r. y'GG� <br /> 2) Vehicle Vin %L7i�%( � —�v <br /> 3) State Decal#: Cake/Model: <br /> 6) Color. <br /> VEHICLE OWNER <br /> , O <br /> Address of Owner. <br /> S d0 k o <br /> City <br /> Otte 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 (CalCode sections 1 shall re 11rt to t If the use of the commissary is <br /> office may re the permit holder must notify this office to make the necessary changes. Fallure to notify thfj <br /> office may result in permit revocation and penalties_ <br /> Si nature of Vehicle Operator <br /> �OIIA�lI SARY INFORMA7t Date <br /> big <br /> Business Name: <br /> Owner Name: ZCZ <br /> Site Address: <br /> sce®caadress - S <br /> Phone: ( ) CRY <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 /> M-ffquid&solid waste disposaltensii washing sink ff�� <br /> R or s oo� R <br /> rft ftt !J Store frozen food p'ash facilities <br /> reparation of food of& <br /> water for deaning oilet&hand washing ❑ Stere refrioerated food <br /> to faod/supplies Provide fable r��"A//' <br /> Po water emfght Parking � tlequate eiecirica!ouL+ets <br /> Si nature of Commgssa Owner/O erator ���7 <br /> HEALTH OEP.+tRTMENT Date <br /> if the commissaryffood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> curMnt health permit by signing below. Coanmissaryffood establishment is in <br /> County. <br /> Signature of County.RENS <br /> Date <br />