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VERIFICA `ON OF VEHICLE COIF IISS 4RY <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 #: A RM O Z 4) Year: — .9000 <br /> 2) Vehicle Vin #: 11U 11 or 5) Make/Model: P(,�\ <br /> 3) State Decal #: 6) Color: '((9 <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: �> -) fir, <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 /> off�ice result in permit revocation and penalties. <br /> - <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: N WM I I Tye v M01 <br /> Owner Name: �/ UM "� ',� <br /> Site Address: � ' 01( '�- - s <br /> Street Address City <br /> Phone: (201) 29'9 — 20 S"I -AS?—(; <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 /> �0 Liquid&solid waste disposal Utensil washing sink <br /> (2 or 3 compartments) �r�p❑ Store frozen food Vehicle wash facilities <br /> 1:9/pr of food L Hot&cold water for cleaning 'v Toil& hand washing ❑ Store refrigerated food <br /> ,� r ,� <br /> to dry f d/suppl' s Provide pot ble water h Overnight parking �dequate electrical outlets <br /> Si _ ture of Com wner/Opemor 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 />