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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): '')Z cr, �qC L ct )re <br /> Address for Vehicle: 76-,), <br /> Street Address city <br /> 1) License Plate#: 70 4) Year: 9 <br /> 2) Vehicle Vin#: 51 Make/Model: A'Al 6.0 C <br /> 3) State Decal#: n) Color: <br /> a <br /> VEHICLE OWNER INFORMATION <br /> Name: L 8 E-I'J 1 f\/ 01 LE ti'C 114 _ _ <br /> Address of Owner: 7 2, �0 0 it j C �15f1 L-1vl /qh �-�-� ''/ <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 /> office may result in permit revocation and penalties. 11;-7 <br /> //6 i /l <br /> Signature.of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: U10 61C C q 25: 111" ,, -1746k" <br /> Owner Name: 1-7 iq Rf N(L <br /> Site Address: 7 S . (, �j(�/U ( 1 GLS( W G <br /> Street Address City 1, <br /> Phone: ( !) 0 57-q ( 6 <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 /> Liquid&solid waste disposal FRsll washing sink , Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food �ot&cold water for cleaning Toilet&hand washing ore refrigerated food <br /> Store dry food/supplies Provide potable water Overnight parking Adequate electrical outlets <br /> Signature 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. Commissaryifood establishment is in _ <br /> k County. <br /> Signature of County REHS �^ __. Date �W <br /> EHD 16-017 0 0`G IVIFPU APPLICATION <br />