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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): 77AL015> ------- <br /> Address for Vehicle: > -S <br /> Street Address City <br /> 1) License Plate#: 4) Year: l� � <br /> 2) Vehicle Vin#: 33 5) Make/Model: C e <br /> 3) State Decal #: 6) Color: — <br /> VEHICLE OWNER INFORMATION a D G gyl7a 3 <br /> Mame: I S CG G��G IC <br /> Address of Owner: Z �� 5{-f Gt MC fA/t T <br /> Street Address - City <br /> t 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 /> Li c 1 o;�, <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ` <br /> Owner Name: <br /> Site Address: _70 & UI' <br /> Street Address Ci <br /> Phone: (z ,� /'��t/� '� 02 l 7 V -- <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 /> sink il washing sin <br /> H41L_`quid&solid waste disposal ❑ Utens ❑ Store frozen food ehide wash facilities <br /> (2 or 3 compartmental nof food of&cold water for cleaningICZernight <br /> t&han washing ❑ Store refrigerated food <br /> ;_G41r�epar <br /> or oodlsupplies ❑ ovide potable water parkinguate electrical outlets <br /> Signature of Commissary Owner/Operator Date _ <br /> HEALTH DEPARTMENT <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 /> Gun a.n,� n _s_ urnasaw �n r�u <br />