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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An Incomplete application may delay approval. <br /> 'C <br /> WW6 <br /> Vehicle Name(DBA): M Ti*e. <br /> Address for Vehicle: 2C, `5-1 tQoWell T- born Friq , (V <br /> StmetAdchen CRY <br /> .1) License Plate t .80g,)d 1 4) Year. -77 1 Tq <br /> 2) Vehicle Vin C' D <br /> Make/Model: (1 <br /> 3) State Decal 4: 6) Color. <br /> VEHICLE <br /> Name: <br /> Address of Owner. 1.1 i0k - <br /> SheiirtAddtess. . . ciiy. 9S�e�116 <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 (CalCode sections 114285 & 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 result in permit revocation and penalties. <br /> VehicleSi nature of Operator Date <br /> COMMISSARY: N "`B"` <br /> FORMATION <br /> Business Name. Pr)rnc�oldrp'c) <br /> Owner Name: e, ' WrCeZ <br /> Site Address: rTO) 0 ac)'3 z <br /> Street Address city <br /> Phone; (209) -74"�Y- -26G-1 <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 /> [']-Liquid&solid waste dlsjasal latilensil washing sink <br /> 9ZOr3compartinuft) StDre Inman food Vehicle wash facilifies <br /> F-1 Preparation of food 2Hot&cold water for cleaning BTcget&hand washing [Store refrigerated food <br /> [Store dryfoodfs les I Provide potable water [2-Ovemight parking aAdequate electrical outlets <br /> Si ana f Commissary Owner/Operator 'Date <br /> If the commissaryHood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit bysigiiing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> PAMf I APPI MAMON <br />