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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />M E! <br />ROX <br />Vehicle Name (DBA): <br />Address for Vehicle: <br />SbeetAddress <br />1) License Plate #7 q 0-M (0� 4) Year. <br />2) Vehicle Vin 'QtINVC(SS's .5)_,,Makelrhlodel:-9 <br />U13 <br />3) State Decal 6) <br />j.V, (C <br />lg-2: SM"MU, <br />Name: .:, \j S St!A&en60 Zo <br />Address of Owner: S <3 I 5V4 -1'O 70v\ .p <br />SLestAddmss 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 & 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 />officemayresult In permit relcation and penalties. <br />I <br />��s <br />??,g — — -- . to <br />Business <br />Owner Na <br />Site Address: <br />Phone: <br />.if <br />1, the commissary owner, can and will provide the nities for the above mentioned vehicle at my <br />WIMM <br />commissary as checked bel <br />E] Liquid & solid waste disposalow��Utensill washing sink <br />f <br />Ej Store frozen food "ehi <br />(2 W 3 C-4w"Mts) wash facilities <br />Ej Preparation of food. F1ot & cold water for cleaning o�flet& hand washing Store refrigerated food <br />' <br />EjStDre dry food/supplies Provkidllpqtablewater_�.' D6"'.might parking Adequate electrical outlets <br />Sl <br />ii:' -sw"gw4W <br />M11 1 .,,1! <br />, <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />current health permit by signing below. Commlssaryffoodestablishment is in <br />County. <br />Signature of County REHS Date <br />EHD 1"17 <br />Sara <br />7h6r2M Fp��PLICATION <br />