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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> :.�IEHICL_ <br /> Mi W'Y,r'.,v 2n r .F '`':�t3���^ '2 y ) s"_� sm F`rr Q ri, wH T <br /> Vehicle Name (DBA): Ash and Oil <br /> Address for vehicle: 1100 Richards Blvd Sacramento <br /> Street Address city - <br /> 1) License Plate M 4NZ1494 4) Year. 2017 <br /> 2) Vehicle vin#: CA1163647 6) Make/Model; SPNS VAN(Trailer) <br /> 3) State Decal#: N/A 6) Color: Cream and Green wrap <br /> �. ... �: K.Fy k. ?'� . 5-2,e, <br /> z. �, <br /> _VEHICLE:OINNER'INFORMA'fIUN>.. iys�ne.�tfT'.ya'�y' y 't `i.:�"�. <br /> Name: Venice Labra <br /> Address of Owner: 33161 St. N. Highlands <br /> Stroet address CV <br /> YS <br /> mobile food facility shall operate out of a commissary and shall report to the commissary at least onceweach <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued a permit holder must notify this office to make the necessary changes. Failure to notify tHis <br /> offlc a esult in permit revocation and penalties. <br /> _ 10/10/17 <br /> Si nature of Vehicle Operator Date <br /> �' <br /> 2 +e ° :r*r"2 kr . Lirm a . a t7.`.. .}rL,_.•y},'1; �1 <br /> CUMMIS§ARYINFORMAT)ON3"-";.,: <br /> Business Name: :T2 \ <br /> Owner Name: 6, t c c, L- <br /> Site Address: o() (� <br /> Street Address 'City <br /> Phone: 611- r <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 /> �iquid&solid waste disposal {J <br /> tensil washing sink ,�tore frozen food Vehfcle wash facilities <br /> r—r�t7P or J coriipaninenrs) ��1J <br /> r2r'reparation of food ot&cold water for cleaning rte, oW�ilel&hand washing Store refrigerated food <br /> ' ,I�fore dry foodisupplies rovide polable water -2 ernight parking dequate electrical outlets <br /> Signature of d&mmissary Owner/Operator Date ���}} u <br /> jtif{ r ? , �' vr^j•'rh aN,.. 1- 1"�:j-r`x MIX <br /> _;HEALTH DEPARTMENT .:;c� .-K. t-fir• ,;�ir'y�.t t�;.r..wT"ni'd' .c- <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 /> EHE 16-W 5et6 MFPU APP.LICAPON <br /> 711 woos <br />