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of Commissary Owner/ <br />HEALTH DEPARTMENT <br />VER.,FICA , ION OF, VEPICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval, <br />v triii..;Lt INFORMATION • <br />Vehicle Name (DBA): —tact) Luc° <br />..._ Address for Vehicle: -9-1-D 5. <br />License <br />Vehicle <br />State <br />Street Address City <br />Plate.#: .....)11 OB q 4) Year: tct _ cie--- _. <br />Vin #: I 61 b 14.irz vc7. 53cca2s895) Make/Model: <br />Decal #: 6) Color' 4 RI Ife_ <br />VEHICLE OWNER INFORMATION <br />Name: VI 0-0 te- uz, 1 --z,j- ,c.-i, rc,/-0 <br />Address of Owner:. 4 y -1-2,c Iti-D vi <br />The mobile food <br />operating day for <br />discontinued, the <br />office may result <br />U t LII)r_______Kea <br />_S Street Address City <br />facility shall operate out of a commissar/ and shall report to the commissary <br />cleaning and servicing (CalCode sections 114295 & 114297). If the <br />permit holder must notify this office to make the necessary changes. <br />in permit revocation and penalties. <br />krZeov., <br />at least once each <br />use of the commissary is <br />Failure to notify this <br />Signature of Vehin Operator Date <br />COMMISSARY INFORMATION <br />Business Name:. 66,) ico r ni... f6v--tity .--i cvo‹. k,./k..bk <br />Owner Name: in Ve.44Ar `k- u ,P-in rye): ' 6-c) <br />Site Address: -, __1 <br />,N 0 S Ca I icEPTIVI S A' ,. <br />Street Address City Phone: (j) 27 1 ..... 13_0 I <br />--:, I, the commissary owner, can and will oro-H, '-'--,‘ lecessary facilities for the above mentioned vehicle at my commissary as cheeked below: <br />1-1/1 ini tiri A cellie4 ,A;nc•+ A;,,,,-1 ! iitenS!! ',/,';:;zh ,-- -1 z r <br />.1. Preparation of food <br />1-11Store dry food!.s_ <br />Store frozen food <br />!-/"Toilet & hand washing <br />Date <br />Vehicle wash facftes <br />Store • = refrigerated food <br />.14.jmn•Liat:,- f2ets <br />(2 or 3 compartmen(s) <br />Hot & cod water for cieanind <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 />END i6-O7 <br />7/18/2003