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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): `.F-,1(6 l <br /> Address for Vehicle: <br /> treat Add'/ �h, <br /> 1) License Plate 4) Year: 2a/lyl <br /> 2) Vehicle Vin#:5RAG3rrl �kO.rfbRf 5) Make/Model: <br /> 3) State Decal* 6) Color. <br /> VEHICLE OWNER INFORMATION <br /> Name: to Orr <br /> - <br /> Address of Owner: <br /> Street Addrsss 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 8114297). 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 t permit revocation and penalties. <br /> gw [-M fa g <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION 1. r <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> StWtAddress City <br /> Phone:(Z 6 -7/ / 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 /> quid&solid waste dsposal washing sink <br /> porawn@aM�mbi irJ---�Ge Store frozen food �facilities <br /> era <br /> ar�ration of foodo[s cold water for cleaning det&hand washing ❑ Store refrigerated food <br /> ZdryfwWsupplies n:;Ze potable water emight parking �dequate eleo cal outlets <br /> 47 <br /> i nature of Corn <br /> Owner/O erator D e / <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 />