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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. Art incomplete application may delay approval. <br /> VEHICLE INFQRMATION.:% <br /> Vehicle Name(DBA): M ' + <br /> Address for Vehicle: 15686 <br /> Street Address <br /> 1) License Plate#: Fes,9 1 4) Year. <br /> 2) Vehicle Vin# (� I�L?iS 1.�33P)7/9q 5) Make/Model: <br /> 3) State Decal#� 6) Color. I fe <br /> VEHICLE 01NNER INFORMATION <br /> Name: <br /> Address of Own er. i _ <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 (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 /> Si nature of Vetticle O�� 7 �rator _ Date Z YJ-25;�p <br /> COMMISSARY INFORMATION , 4. <br /> Business Name: <br /> Owner Name: <br /> 1 PrreZ <br /> Site Address: t7020 'a . 2 <br /> StreaAddress cay <br /> Phone: (2-09) - - 6 <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 /> Liquid&solid waste disposal B Utensil washing sink Store frozen food Vehicle wash fecNes <br /> (2ora mmpaAPnnts) . <br /> Q Preparation of food 21-lot&cold water for deankng BToitet&hand washing Store refrigerated food <br /> jd,,y216od16u les Q Provide potable water Q'Ovemijjght parking [TAdequate electrical outlets <br /> Si na f Commissary Ownerl0 erator Date <br /> HEALTH DEPQRTMI=NT <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 /> Signature of County REHS Date <br /> eun+e n+•. 5.d c WPPI I APPI IrAMON <br />