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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): C,r -- - - � --- <br /> Address for Vehicle: <br /> Street Address - - — <br /> City <br /> 1) License Plate#. s F s R 4) Year. —j_$Lc� <br /> 2) Vehicle Vin #: LTJ Make/Model: _—a'A-t G <br /> i <br /> 3) State Decal #: _ 5) Color: Lvh -Z <br /> VEHICLE OWNER INFORMATION <br /> Name: V I I tc'aU-e-V <br /> Address of Owner: SGIC, y� <br /> Street Address City --- _----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 (CalCode 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 Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: I C� -- --- -— <br /> Owner Name:}----Q Q �`------ - --- ---- <br /> Site Address: �y� $ . AgrooY�- 1 , cyt S,fzj k CA <br /> Street Address City <br /> Phone: (Zp ) Z � <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 /> Liquid&solid waste disposal _ Utensi;was' rg s:r.k Wg±cre frozen food Chicle wash facilities <br /> y2 or 3 compartments) � , <br /> r paration of food !�'—I{/Not&cold ^pater for r_;eaning Toilet&hand washing Cil S re refrigerated food <br /> Store dry food/supplies (provide Dv c.b!a er k , <br /> U t �:G C. I �Jverrrchi pzrf nq Adequate e'ectrical cutlets <br /> -12--7- 1(3 - -- <br /> Si nature of Commissa caner/ er Date <br /> HEALTH DEPARTMENT - <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 /> EHD 16-017 <br /> 7i'18/200,5 c"` G F I „f- <br />