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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all Information requested. An Incomplete application may delay approval. <br />�(EMIGLE,INFORMA fIONsyu'',!�s. 4 ,~E' �? y <br />r <br />JONN ..ti rs .•i j.._.,,. N �4ssiass �:�:L _..e_o-z'� wFS• _ � <br />Vehiclexmm- <br />Name (DBA) T <br />Address for Vehicle:. Z - SGb <br />1) License Plate#: L( (5 L [39 4)) Year. ZD ZO <br />2) Vehicle Um #: Z-&���01'I5) 3Make/Model: <br />3) State Decal #: 6) Color. ( gD �Llt <br />�/ENICLE OWNER INFQ AT10N`:' ^�Tr s n s ' r� •'t Yrs �; v, <br />_....SS".fny..i..'�,"n.6=c.. <br />Name: <br />Address of Owner. Ucc �C -C 78 <br />_ Sheeta cfir <br />The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each° <br />operatingday for c nirt9 and servicing (CalCode sections -11429S & 114297). If the use of the commissary Is <br />discontinu th it holder must notify this office to make the necessary changes. Failure to notify this, <br />offi ay res �revocatton and penalties. <br />9 2 - <br />Si natu ehicle O rator Date <br />V6214+a^.V.�Sy �. tiT?R"iYfN�4V91{ lrC+�^. 5 S•h <br />OMMISSA Y�IRiFURMA770N+i'�``".. <br />17 <br />Vie...._... '� ..d.%.l.t. ?'i'f Nt3rs± .oY'Sia`�,.'%•�rvv'ays.('�'Si _4+w!•''�fs�`:"L. yiV�"-.'#Y. <br />Business Name: <br />Owner Name_ \e c <br />Site Address: 1J3 . S(QGrO.Yv�Q flh0 S <br />street Address <br />Phone: ( ) 22 — 33LA <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 Utensl wast1 i <br />sink <br />12or7,W Store frozen food ® Vehicle hash ladtites <br />Preparation of food Hot & cold water for deanhV 0Totlet & (rand vrasfdng •® Store refrigerated food <br />Store dry ft&KWms [` Pfovide potable water N Nighl pal" [� Adequate electrical outlets <br />G4. 7-27-Z( <br />Si nature of mmissa Owner/Overator Date <br />•r- <br />�HEi4L,�TF11Dl=BARYAAENi�'-�=y��''�'��,�'s`�r <br />If the commissaryffood establishment is outside San Joaquin County, the local health jurisdiction must verity <br />current health permit by signing below. Commissary/food establishment is in <br />County. ' k <br />y � <br />Signature of County REHS >°Y' Date <br />EKD 1"17 sof 6 MFPU APPUCAT*N <br />7parto08 - � <br />