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l--v <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval: <br /> Vehicle Name(DBA): � <br /> Address for Vehiclex C S•� L�2 t11—�it i�i�C i, (� ( �tSZ�o <br /> 'StreetAddiem city <br /> 1) License Plate#. y S S 6.a® 4) Year. ZEA 1g <br /> 2) Vehicle Vin 9 J�RG Cr25IC 1 � MakefModel: <br /> 3) State Decal It 6) Color <br /> azasr- <br /> �,�/Ekt1�L�`E:�N! <br /> Name: ALa.� yL �t <br /> Address of owner W6 7T0QdTb0 i2d` -1---TZ04 O N Cis Zvo <br /> . Street Address CRY <br /> The moble 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 (CalCode sections.114295 8114297). N 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 m result in permit revocation and penalties. <br /> Signature of Vehicl Operator Date <br /> At 4:T' =^nt=viaL'• <br /> AVON— 01-0- <br /> Business <br /> F-0A.• <br /> Businesse- <br /> •::S'.xl".l":`4�-tia1YJ..i•.c�y:.y�isR...r.-r �.vb7+.�y'�`-~.�'-ki� <br /> Name: ro <br /> S4,;- <br /> Owner Name: t, <br /> Site Address: a�.ru.� 4- <br /> 5 <br /> t A—d rens Cay <br /> Phone:(Zoq ) �/ 3 <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> ,c�ommmissaryas checked below: <br /> IJ Liquid&sorid waste disposal �lensd thing sink �m�n f� UVehide wash faariues <br /> (1 m3 CompadmeNs) <br /> ❑raro <br /> Preparation of food L UIQ&and ma for dmniny re,Tl`m7et&r�ana washG,y ml"� fe'`tiy—d f� <br /> -- re dry tWsuppiies [�yide potable waterD 6t mP9hDG <br /> t Paitrig quare electrical outlets <br /> LLSiniffiure of Commissa Owned rotor .Date <br /> �-...»c a+ca3 �.. Ti��&.�.. Js,.:.ii'S:•��v �_.t,ezw LY 3',�i:s �7..: �' <br /> If the commissary/food establishment is outside San Joaquin County,the local health Jurisdiction must verify <br /> currentbealfh permit by signing below. -Commissary'Kood establishment is in <br /> County_ <br /> Signature of County REHS Date <br /> END 16-017 s m s MFPU APrucanoN <br /> 7/182008 <br />