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0112 "N Nv" '8 11H '86 ""V atoll P a A I Da a <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested: An incomplete application may delay approval. <br /> Tw3w -M75155 <br /> MAE <br /> M.M <br /> Vehicle Name (DBA): `5 115 <br /> Address for Vehicle: 110C) <br /> Street Address city <br /> 1) License Plate#: <br /> 4) Year: z01 U <br /> 2) Vehicle Vin #:L4tJ2-NAVJ b0o/ cA( 04, 5) Make/Model: �cx <br /> 3). State Decal #'. 6) Colov. <br /> qnzy <br /> RON W WE$ --f"014 1,04 OR <br /> Name: <br /> Address of Owner: 4JO <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 (CalCodo sections <br /> ;ns 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 /> 0 e may result in permit revocation and penalties.. <br /> 'QA <br /> §9nature of Vehicle Operator Date <br /> 0 <br /> It <br /> 0 <br /> -15 <br /> _0 <br /> Business Name: <br /> Owner Name: <br /> Site Address: ILc)() <br /> Straet Address city <br /> Phone: <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: I <br /> D� iq­uld&solid waste disposal.. E7[Utensil washing sink -Store frozen food E�JVehicle wash facilities <br /> (2 or 3 compartments) <br /> 2PreIp:irafio6offo6d --ffHot&cold water for cleaning: -Toilet&hand washing Q-�Store refrigerated food <br /> J: 'Store dry food/supplies Provide potable water E2Tv-ernight parking �Adequate electrical outlets <br /> gnature of C6mmissary Owner/Operator j Date <br /> Wq 4 W,W-1 <br /> If the.commissarytfood establishment Is outside San Joaquln County, the local health jurisdiction must verify <br /> current health permit by signing below. Commissarytfood establishment Is In <br /> County. <br /> Signature of County REHS i Date <br /> EHD 16-017 5 Otis MFPU APPLICATION <br /> 7/18/2008 KIV V0:6 LIOZISZ/80 Z JO Z 86% 8CL0-t'W60Z) :XCJ :01 LBL6-86t(998):XeJ 4GU4-QS 4SOJON:WOJJ <br />