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e errant: INFORMATION <br /> Vehicle Name(DBA): <br /> Address for Vehicle: C, Tiov4_, <br /> <3 <br /> Street Address <br /> City �U" <br /> 1) license Plate <br /> 2) Vehicle Vin#:j°7 '— 4) yyY��ear (Q/ <br /> ke/Model <br /> Z : <br /> 3) State Decal#; _ <br /> 6) Color: <br /> VEHICLE OWNER I'llFORI4YATtOAI <br /> Name: a7lZa �l <br /> Address of Owner. <br /> / <br /> Street Address � �/� 0 <br /> The mobile food facility shat)o ry R CHY commissary Perste out of a commissary and shall report to the commissa at least once each <br /> operating day for cleaning and servicing (CatCode sections 114295& 114297. if the <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> d aY salt In l use of the commissary is <br /> Permit revocation and penalties• <br /> ire of hide Operator <br /> COMMISSARY INFORMATION Date <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> so-eec,wd, <br /> Phone:( C c <br /> � o —l <br /> 1.the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> fCoommis! ary as checked below; <br /> Zerabono <br /> disposalOVf sd washing sink <br /> Iz or s rm�,,rm ❑Store frozen food <br /> L�'1�f food Vg;cle wash facilities <br /> of&�Vfd water for cleaningToilet&hand washing <br /> foodisupplies Q Store refrigerated food <br /> de potable waferfight parking (� ,,�� <br /> r�"tlaq� re e�l outlets <br /> S' nature of Commissa Owner/0at. <br /> T <br /> HEALTH Dt:r^RTMEIYT Date If the c health Permit <br /> d establishment is outside San Joaquin County,the total health jurisdiction must verify <br /> Curter health permit by signing below. Commissaryffood establishment is in <br /> County, <br /> Signature of County.—RE—HS <br /> Date <br />