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VERIFICATE" N OF VEHICLE COM SSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> R' <br /> &FkMllMUarr324 <br /> +s <br /> Vehicle Name (DBA): At a r� Wlotx, <br /> Address for Vehicle: cjg L W A76 P o (lTet� 45 s <br /> Street Address City Zip Code <br /> 1) License Plate 4) Year: 1�I <br /> 2) Vehicle Vin #: 9,2 `\ L1EF23 N lytl c�gi 5) Make/Model: ()Q AT CAtCnZE tt <br /> 3) State Decal #: 1- 7 tc Sa 6) Color: 01 _ ?01 y61Low <br /> T_ <br /> Name: A�r(0-4 <br /> Address of Owner: 1 C�-i 'G, v-M 1., cc' U v. cp.' X151 3 <br /> Street Addrrs Ciry Zip Code <br /> The above-mentioned vehicle shall operate out of a commissary and shall report to the commissary at least <br /> once each operating day for cleaning and servicing [CURFFL 114265 & 1142871. If the use of the <br /> commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br /> Failure to otify this office could result in permit revocation and penalties.ec <br /> 6xc <br /> i nature of Vehicle Operator Date <br /> �,�r�,a< a� xT,��11 +- r{ yul,x� �a{s'+ iJay4�{rY+(N?Y I ry Yr iyGj� - nYa r h9 +b 1.�"'ii s .tYl <br /> 1VOlY11Y11Uci rJ _1'©I1TO i\ 3L y YIFM 20Un 6. 1� S Y 4 1_ r1 �_{ttr +)fi <br /> . Y_ +.,. . ..�'2 t c .9t..,.,t+.r E.s.,..e r_w -.Pad. X, ha ... r..es.,_.rt� }e sirR ..,.,].s i...�4, w -.aR? ,.,n:w_iw;:� <br /> Business Name: <br /> Owner Name: <br /> Site Address: l0,yL Wa �vtuJ A4 <br /> Street Address City Zip Code <br /> Phone: <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at <br /> my commissary as checked below: <br /> 1K.quid&Solid waste disposal ❑ Utensil washing sinkStore Frozen Food dProvide ice <br /> (2 or 3 compartments) <br /> Preparation of Food Q Electrical Hook-up Toilet&Hand washing Vehicle Wash Facilities <br /> Store Dry Food/Supplies Lt-1 Provide potable water Overnight Parking Store Refrigerated Food <br /> Si nature of ommiss Owner/Operator Date <br /> .- 1 vu ..r V <br /> rg AILTII b' < c 1�i►`� s�!` 1 1 ' N ftY}�'P r k P ? f.�t.n3..+ T'� �� th,wst kT3' e5i_ --6'rh+ 't^trA 4:Y f, �F'.k"`I v" <br /> •r'•L��.Yn ;+.aT�: �{„�;�"l9._ <br /> If the commissary/Food establishment is outside San Joaquin County, the local health jurisdiction shall <br /> verify current health permit by signing below. Food establishment/commissary is in <br /> County. <br /> Signature of County E.H.S. Date <br /> EHD 16-01-013 Page 8 of 8 MFF APPLICATION <br /> 5/12/2003 <br />