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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): Y� l <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: "/// ��__ 4) Year: <br /> 2) Vehicle Vin #: 41IZ4 C3/41a3 EK O rt &,r,- 5) MakelModel: <br /> 3) State Decal* 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: <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 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 i permit revocation and penalties. <br /> )1\A <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION r <br /> Business Name: <br /> Owner Name: <br /> Site Address: &14 44e2lt <br /> Street Address city <br /> Phone: (Z Ce,( U <br /> f,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> squid&solid waste disposal ensil washing sink ❑ Store frozen foodc e wash facilities <br /> (2 or 3 compartments) <br /> reparation of food q1lot&cold water for cleaning rlet&hand washing ❑ Store refrigerated food <br /> r dry food'suppliesrovide potable water ernight parking_&lodli_'&e'ee7'���_ q <br /> Adequate electrical ous_!e s <br /> i nature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verity <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br />