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VERIFICt8 TION OF VEHICLE COMMISSARY <br /> ['lease provide all infor- .ion requested. An incomplete appl. ion may delay approval. <br /> No <br /> Vehicle Name (DBA): <br /> Address for Vehicle: c) ahkD22L <br /> 3)/ <Jry- k-�)4 4-2 E; <br /> Street Address City Zip <br /> 1) License Plate 4: �-7 /5- 49— 4) Year: — <br /> 2) Vehicle Vin ft: 16tr14P3'�!K)(C Z&o ) MakciModel: <br /> 3) State Decal #: 6) Color: <br /> .A 1j esS Of Otivner: � � <br /> Street Address City Zip <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least <br /> once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of <br /> the commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br /> Failure to notify this office may result in permit revocation and penalties. <br /> Si azure of Vehicle Operator Date <br /> Business Name: y <br /> O«Jner Name: <br /> Site Address: <br /> Street Address city Zip <br /> Phone: p a:j7 <br /> I,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at <br /> nay commissary as checked below: t <br /> iquid&solid waste tensil washing sink <br /> disposal (2 or 3 compartmests) ❑Store frozen food e�icle wash facilities <br /> ;Zrs'��4' n! <br /> f food of&cold water for cleaning tet&hand washing ❑ Store rehigerated food <br /> food/supplies ��rov<.dtWe water emight parking equate electrical outlets <br /> i v lature of Commissary Owner/Operator Date <br /> •_t <br /> If the commissary/food establishment is outside San Joaquin County, the local health ,jurisdiction must <br /> verify current health permit by signing below. Conllnissary/food establishment is in <br /> County. <br /> Signature of County R.E.H.S. Date <br /> END 16-013 Page 8 of 9 MIFF APPLICATION <br />