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VERIFICATION OF VEHICLE COMMISSARY <br /> Please_provide all Information requested. An incomplete application may delay approval: <br /> W. <br /> Vehicle Name(DBA): L r <br /> Address for Vehicle* L64 <br /> rese r4 <br /> 1) License Plate 2: .2 J G - 4) Year <br /> 2) Vehide Vin It- Makefflodel: Z- <br /> 3) State Recal k. 10 17- NIS 10L�12 <br /> Name- 4� <br /> Address of Owner /7 PJ-2 <br /> StrmtAddms <br /> The mobile food facility shall operate out of a commissary and shall report to the cominissary at least once each <br /> operating day for cleaning and servicing (CWCode sections-J14295& 1142M. H 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 /> offlGe may mutt in permit revocation and penalties. <br /> Si mature of Vehicle Pperatar Date <br /> Business Name:11'0w!ner Name: k\ QAd0aS�Q� C-r-xcci e) <br /> Site Address: L'(D <br /> stmatj city <br /> Phone: (2N 2-7-,LA - <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 /> IKUquid&solid waste disp3sal Utensil washing sink <br /> m frozen food <br /> (zar3ca i i aft) b� Vehicle%vmh facilities <br /> [A Pmpraiin of 1bW i-fot&cold Waber for CleaningT-9-t&hand wasithq 'VI Stem�tb,,j <br /> V <br /> Store dry fmidlaupplic* Wovide-potable voter mild pang V fij*unta ge*cEd Guffets <br /> SigI <br /> 'grilft, re Qf nmrmssary OvMer/Operator Date <br /> If the commissairyfibod establishment Is outside San Joaquin Gouuly,the local health jurisdiction must v9ft <br /> current-health permit by signing below. -Comniis-sarynbod establishment is in <br /> County_ <br /> Signature of County RENS Date <br /> EHO 1"17 s of s MFFU APPUCAMN <br />