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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested_ An incomplete application may delay approval. <br /> VEHICLE INFORMATION 4 <br /> Vehicle Name(DSA): <br /> Address for Vehicle: 3 �. <br /> Street Address City <br /> 1) License Plate#: �Jo 1 �1 5 �4) Y ar: <br /> 2) Vehicle Vin#: 14 F,37— A45-F33z. 5) Make/Model: GyLfiy <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: 3 (3 3- <br /> Street <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 & 144297). 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. <br /> LSna'ture of Vehlcie O rator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: r� <br /> Site Address: C:�> G G <br /> Street Address City <br /> Phone: �2 Cel U <br /> 1,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 2 Densil washing sink Store frozen Food ehicle vrash facilities <br /> El"rep of food Hot&cold water far cleaning oilet&hand washing ❑ Store refrigerated food <br /> St ry toodfsupplies rovide potable wafer vem�ght parking Adequate electrical ouVe s <br /> !Signature of Commissary 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. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br />