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........... K.......... I <br /> RX <br /> Vehicle 114anie(DBA): <br /> 706-,��S 001-96- 7­ �-' <br /> Address for Vehicle- Lc LL, <br /> Street Address . -Cit -�) - 7-- :7 <br /> Zip <br /> 1) License Plate#: 4) Year: <br /> 2) <br /> V) Make;Nllodel: 4-7 <br /> 3) State Decal #: 6) Color: <br /> Street Address Citv Zip <br /> The mobile food facility., shall operate out of a commissary and shall 4-eport 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 /> Signature of if Vehicle Opaator Date <br /> Business Name- <br /> "2q L eZAA' 64 <br /> O-caner Name: <br /> Site Address: <br /> Street Address <br /> City Lip <br /> pholie:(&* <br /> 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at <br /> my commissary as checked below: <br /> iquid&solid waste ��tlllil washing sink <br /> di.Tosal (2 or 3 compartments) <br /> ❑Store frozen food �icle wash facilities <br /> [�<V- arae f food <br /> �,(epr-lp ; 04ro-t&cold water for cleaning 5176ife-t&hand washing E]Store refrigerated food <br /> an,f,,o <br /> )rq'4 <br /> tor dry foodisupplies �<<,idewblc water uer-C� Aequate electrical Might Parking E4 -J- outleis <br /> L <br /> n /n,." <br /> ignature of Conirrnislsamyl 01-Nineli/Operatior Date <br /> 4 R—1— <br /> It the commissary/food establishment is outside San Jo .10�01-00k` <br /> R� <br /> 0=6 <br /> WM— <br /> OM <br /> IN <br /> N_-&_ <br /> Jill <br /> Joaquin Count)!, the local health jurisdiction must <br /> Verify current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County R.E.H.S. Date <br /> EHD 16-013 Page 8 of 9 <br /> I g T C- TION <br /> S.17:200' --%PPLILA <br />