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VERIFATION OF VEHICLE CO&IISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Blame (DBA): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#-. �/ �J� 4) Year: l <br /> 2) Vehicle Vin#:l cTj�3o2 33toZC�'$� MakeiModel. <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: L L 1-46-- > e-.,-, c 0 <br /> Address of Owner: d , o>< <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 S 114297). If the use of the commissary is <br /> discon ' ed, thpe�mit ho must notify this office to make the necessary changes. Failure to notify this <br /> 7 <br /> offi ma resulf,in er revocation and penalties. <br /> 11�7 _ <br /> Si ature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: l o- <br /> Owner Name: �. <br /> Site Address: o :S, <br /> Street address ci#y <br /> Phone: g�j) G 9� 7 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 /> squid&solid waste disposal [4-Ufeensii washing sink ❑ Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> reparation of food of&cold water for cleaning oilet&hand washing ❑ Store refri erated food <br /> tore food/supplies Ovide potable water vemight parking dequate electrical out!ets <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 verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County RENS Date <br /> J <br />