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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): \(J (r t NG <br /> Address for Vehicle: 9S t`i�� o C�FkVvtFyt <br /> Street Address City `1 <br /> 1) License Plate#: �C N �2(n� 4) Year: WA0 T <br /> 2) Vehicle Vin#: \ZC\cEi`t231RLllsb'ISl:;, 5) Make/Model: N'K\ �5\ybt4C1� <br /> 3) State Decal M 6) Color: <br /> VEHICLE 0WNEIdNF..ORMATI6N <br /> Name: SU6AVXIE SU(�lll.io <br /> Address of Owner: ( Ie5ko 0I5"1rl <br /> street Address city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating d9oor cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontin the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office r tlt in permit revocation and penalties. <br /> SiRnatu Vehie Orator Fate <br /> :COIN' i RY+IN A�TfON Tx . `4 �n <br /> Business Name: uG. e'k- <br /> Owner Name: n C' S I` <br /> Site Address: ( (0C-3 2,-c-.,--s I, (27. 3 r,-a cc�.c✓� <br /> Street Address City <br /> Phone: C-11c') L(4' Fs 'i -1 B 1 <br /> I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle aImy <br /> commissary as checked below: <br /> Liquid&solid waste disposal 4f-j Utensil washing sink <br /> (2 or a o Psrbnents) tore frozen food Vehicle wash facilities <br /> separation of food allot&told water for cleaning Lf Toilet&hand washing Store refrigerated food <br /> Store dry food//supplierscol de potable water JD'6vemight parking Adequate electrical outlets <br /> Si nature o Commmsa Owner/Operator Date <br /> E _rbc: _ z 7 <br /> If the commissarylfood establishment Is outside San Joaquin County,the local h941th Jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in czx-m- rt 1 <br /> County. /J <br /> y..�rne of county REHS 01 <br /> Date <br />