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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ffCfFQfm fE}Itxc , mrF. . <br /> Vehicle game(DBA): <br /> Address for Vehicle: 7Z,.0 <br /> Street Address City <br /> 1) License Plate* -7 R 1?4�a33 4) Year: <br /> 2) Vehicle Vin#: 1 C7�'J�9C.3A,K3w133 01620 Make/Model e� _ <br /> 3) State Decal#: 6) Color. <br /> _ w - <br /> Name: ftqgw <br /> 2 S _ 8.5 <br /> Address of Owner: Z �G <br /> Street Address Cify <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at feast once each <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). if the use of the commissary is <br /> disconti the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> c may result in permit revoc n a penaf4ies. <br /> L-9 / �/ b <br /> € nature ofVehICIE O erat Date <br /> Business Name: / <br /> i <br /> Owner Name: <br /> Site Address: <br /> Address � <br /> Phone: <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehic"te at my <br /> commissary as checked below: <br /> r7; �ld&�-solid waste disposal tensil washing sink ❑Store frozen food ehide wash facilities <br /> `Lux'•-•`+"""'" (20r]mnV2 ent6) <br /> Q$regaration of food of&cold for cleaning e &hand washing ❑ Store refrigerated food . <br /> �foodtsupplies Provide potable water fight parking equate eiectripl outsets <br /> S nature of Comm.ssa Owner/O erator Date <br /> If ale corninlssaryffood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissarylfood establishment is in <br /> County. <br /> Signature of County RENS Date <br /> 5 of G NFPU APPLICATION <br /> EHO 15-017 <br /> uisrzaaa <br />