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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): (� �� L'7 (� 'S ;I— <br /> Address <br /> 2Address for Vehicle: <br /> Street Address 11 rr— city <br /> 1) License Plate#: 4) Year. <br /> 2) Vehicle Vin#: q7-18F/Fk�(EY96332/ 5) Make/Model: 7l G <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: � j j/ <br /> Address of Owner: (f <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 (CaiCode sections 114295 & 114297). 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 mire tdt in permit revocation and,penalties. <br /> /�2-11,�;/ ; <br /> Sig ure of Vehicle Operator Date <br /> COMMISSARY INFORMATIO <br /> Business Name: <br /> Owner Name: <br /> Site Address: 7,30 — G <br /> Street Address City <br /> Phone: (Z ) Zc> 7/ / <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 /> iquid&solid waste disposal tensil washing sink Q Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food E41 rot cold water for cleaning Mioilet&hand washing ❑ Store refrigerated food <br /> Stor ry food/supplies U4rovide potable water vemight parking231M equate electrical outlets <br /> Si nature of Commissary Owner/Operator Date <br /> HEALTHIZEPARTMENT <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 /> r <br />