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�IWON WJ7�:Zl 9[0Z '9 '�nr ;Wli PaAI ;3;� <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> o •:4 <br /> Vehicle Name(08A): <br /> Address for Vehicle: <br /> Met Kildress city <br /> 1) License Plate#: ViTt 4) Year. AW 7 <br /> 2) Vehicle Vin#: '5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> Name: <br /> Address of Owner: a 37 <br /> 4Street Ad ss City <br /> l.'7 q - v r <br /> The mobile food facility shall operate out of(d 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 in permit revocation and penalties- <br /> 0 ,11i e-11 --j0q6r-q1e,5 - C//J- /a <br /> lature of Vehicle Operator Date <br /> Business Name: <br /> Owner Name: <br /> Site Address: -� { <br /> Street Address City <br /> Phone: ) <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 /> Liquid&solid waste disposal L� u'tensil washing sink <br /> or S comparbnentsl ❑Store frozen food 0/vehicle wash facilities <br /> Preparation of food riot&cold water for cleaning oilet&hand washing Q Store refrigerated food <br /> Store dry od/supplies ovide potable watervemight parking /dequate electrioal outlets <br /> 114�J - 06, 27- 16 <br /> nature of Commissa Owner/0 erator Date <br /> I illillimilmi.111.11, <br /> E., 1, - <br /> If the commissaryffood 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 /> C n <br /> � 6 6 <br /> Signature of County REHS -[3ate <br /> 18 17 <br /> 7!18118!2008 5 of 6 MFPU APPUCATIoN <br /> - <br />