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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An,Incomplete application may delay approval. <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> street Address city <br /> 1) License Plate#: s a 4). Year. -7-711A <br /> -- 'r- <br /> 2) Vehicle Vin C' 5) Make/Model: <br /> 3) State Decal# 0& <br /> 6) Color. <br /> VIEWCLE,QWNER1NFIjRdIATioN :.= <br /> Q <br /> Name: <br /> Address of Owner <br /> klmj CL N - 6 <br /> Street Address , City. <br /> The mobile food lacillby 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 114295 & 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 /> e2 <br /> Signatuj'r'eMV7e-hicI4 DR Data <br /> Business Name: Y-n C2 cild mc) oir <br /> Owner Name: <br /> t4i �rlleZ <br /> Site Address: Z�T02 IT-OK 99GI)z <br /> ShWtAddnSS city <br /> .Phone: (2 -mg-C.C. C)o (20�) Go-5- <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 /> Uquid&solid waste disposal alltenmi washing sink <br /> por3comparbnmts) Store frozen food Vehicle wash facilities <br /> Q Preparation of food [-}-Hot&cold water for cleaning [E[Toflet&hand washing []Store refrigerated floo.d <br /> [Store dry fooNsup flies Q Provide potable water [a0vernight parking [TAdequate electrical outlets <br /> SignaW&CommissaV Owner/Operator Date <br /> z <br /> If the commissaryflood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit bysj7giiing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> UM I APPI KATION <br />