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VERIFICAON OF VEHICLE CC MISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name(DBA): <br /> Address for Vehicle: O �' <br /> Street Address City Zip <br /> 1) License Plate #: 4) Year: ;Z0/0 <br /> 2) Vehicle Vin 4tpg ]�Sj Make/Model: � <br /> 3) State Decal#: 6 Color: <br /> IWON <br /> Name. <br /> Address of On,ner: /l <br /> Street Address Cih' Zip <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least <br /> once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). if the use of <br /> the commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br /> Failure to notify this office may result in permit revocation land <br /> /penalties. <br /> Si ature of Vehicle O)erator Date <br /> �O y <br /> Business Namz a �� ' <br /> UwnerName: Srti <br /> Site Address: 3v S. �2G <br /> Street Address City Zip <br /> Phone:(Z U G / 7 , <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 /> Id&solid waste Ca,4&y q washing sink <br /> disposal (2 or i mmp.rimem) ❑Store frozen food a&ash facilities <br /> ?reparation of food of aF cold water for cleaning t_fd-+O11e�d hand washing ElStore refrigerated food <br /> Store foacYsuppliesroeide potable wateremight parking equate electrical outlets <br /> atureofCommissary Owner/ erator Date <br /> If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must <br /> verify current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County R.E.H_S. Date <br /> EHD Ih-013 Page S of 9 nIFF APPLIC-ATION <br />--y 81712001 <br /> 1 <br />