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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> shsettAwmss cny <br /> 1) License Plate#: Z/ 4)4)3Year: 72r� <br /> 2) Vehicle Vin#: LAJ 21J-7-nA/ao'>X' , 3) LkeNodet: e4,,?y&AI <br /> 3) State Decal* 6) Color �'h kr444-4 <br /> A: MWOMMEN,IM- I-,," I <br /> ,s <br /> Name: <br /> ty <br /> Address of Owner: <br /> ' StwitAddoess c <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{CatCode sections 114295 & 114297). If the use of the commissary is <br /> dissontimidd, 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 /> Sre of Vehicle r Date <br /> - <br /> Busirms Flame: L' <br /> Owner Name: <br /> Site Address: 6- <br /> __. . - - <br /> StreetAWFiria .clly <br /> Phone:(� �� / <br /> K- <br /> I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below04" <br /> :77-tl�� {-� ����,��� <br /> &solid waste disposal 04 "sg washing SHdc ®Store frozen food �lehi' Wash fadNties <br /> // (i m J caxparbenta) <br /> ['Preparation of food 2�14o—t5 cold water for deaning 651et&. hand washing Store refrigerated food <br /> dry foodfsuppries videpot89te Water vemight parking 915;�Uate elect ical millets; <br /> 5. . __ of C ' - - - Owner/O -tor Date <br /> Nthe coritmmarytfood establt8hnient is outside san Joaquin County,thelocal tteaith;urisdiction mustverify <br /> current health permit by signing below. Commissaryflood establishment is in <br /> county. <br /> Signature of County RENS Date <br /> EM 1"17 50M MFPW APPLICATION <br /> 711&2008 <br /> �� boa��5y <br />