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VERIFIPATION OF VEHICLE CCAMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name(DBA): <br /> Address for Vehicle: (=) <br /> Street Address city <br /> 1) License Plate#: �J� �/ 4) Year: <br /> 2) Vehicfe Vin#:l cTi�3v21N 33�oZC S� Make/Model. <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 /> discon ' ed, th�p+r�lrrtit ho must notify this office to make the necessary changes. Failure to notify this <br /> offi ma result,in er revocation and penalties. <br /> /�7 _ <br /> S6rature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name_ l <br /> Owner Name: <br /> Site Address: <br /> Street Address city <br /> 7Z// <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 /> uid&solid waste disposal EA-Ufe_nsii washing sink <br /> q2 or 3 co Store frozen food Vet+ie wash facilities <br /> • ( mpartmeats} <br /> reparation of food of&cold water for cleaning oifat&hand washing ❑�dequate <br /> erated food <br /> tore loodissupplies Ovide potable water vemight parking ectrical outlets <br /> i nature of Commissa 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. Commissaryffood establishment is in <br /> County. <br /> Signature of County REHS Date <br />