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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval, <br /> Vehicle Name(DBA)_ L /-�Z <br /> Address for Vehicle: <br /> 2aWA—dd�rem //��/// CtYy <br /> Z:Zl <br /> 1) License Plate Z ?/ 3 Q 4) Year: <br /> 2) Vehicle Vin 4P5) M ake/Model: Z- <br /> 3) State Decal*. &lor /-?Z- -12 <br /> 777- <br /> Name: t. jf <br /> Address of Owner <br /> StrestlLdd/ress <br /> City - <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating day for cleaning and servicing (CalGode sections 114295& 114297), if 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 /> office may result in permit revocation and penalties- <br /> Signature of Vehicie Operator Date <br /> ON <br /> Business Name: <br /> Owner Name: o' lmay'm C-ffxcck� n <br /> Site Address: ln4- Locs` C)'S-z L'(0 <br /> Street address CRY <br /> Phone: QN LA - �)7)3L( oc (ZpCj) (0(.03-s-i?WS <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 /> 1K Liquid&solid waste crisposal V Utensil washing sink <br /> vora mmPartinents) 0-st",ftmen rood Vehic6 wash facilities <br /> F1 Prepainfion of f..d vi-fat&cold water for dearihV VT-aet&hand washing SWM reidtle a4 rood <br /> Store dry fooffisupplim J*rovide poMle Yker MOWmigM parking Adequate a[a&ical outlets <br /> Si nature of'Commissary er/operator Date <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. CommisssaFy/lbod establishment is in <br /> County. <br /> Signature of County RENS Date <br /> EHD 16-017 Gfa MFPU APPLICATION <br /> 711812008 <br />