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VER C `TOOM OF VI NME C O MESS A RY <br /> Please provide all information requested. lin incomplete application may delay approval. <br /> VIEHICLE WFORWTIM. ; <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> SMt Addrew City <br /> 1) License Platet 4) Year. <br /> 2) Vehicle Vin*. /C�&d':&.S L�Id 5) MakelModel: <br /> I 6) State Decal ft: �� 6) Calor: 7777 <br /> E <br /> i <br /> 'r '``��kQbC�� -.IJV CV��`c-�4V�M4bdi�'P� �YV.-. i• . <br /> I Nance: s •, L� - �� <br /> Address of Owner: I kz'3 i'S 10 c' <br /> t Street Address M <br /> g <br /> i the anobile food facilibj shall otoeraLa out o;a commissary and shall report to the commissary at least once each <br /> operating day for cleaning and servicing (GalGode sections 114295 & 114297). If the use of-the commispenj is <br /> I diseoretlra ees, the permit holder must notify this office 'to make the necessary changes. Failure to notifij this i <br /> o€-lice may?esult in permit revoc "ora and penalties. t <br /> i <br /> P,/? <br /> ignature o Vehicle Operator Date <br /> �s -5 <br /> v0MMINARY WFORMAT-10 '; <br /> i Business Name: <br /> Owner Name: �-�. \R `' tt1. n`' s'� i`i 1 f• _ _ <br /> ? Site Address: N 00 ILL.. 4 ✓ 1 <br /> 5treetAddrass - T I r city 4� <br /> ` Phone: <br /> ±,~Ile commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at MY <br /> cbsramis5a y as checked bealow: <br /> .r .Liquid 1r solid waste disposal Utensil washing sink Kp <br /> ❑Store frozen food Vehicle wash facilities <br /> i (�3 compartrnertsl <br /> a ❑ Preparation of food Hot&cold water for cleaning ©Toilet&hand washing ❑ Store refrigerated food <br /> ❑ rote d,food/supplies %�Provide potable water ,' Ovemight paddng Adequate electrical ouflet5 <br /> Signature of Commis ary OwnerlOpera Date <br /> 3 <br /> 2 <br /> l 11"the cornmissatIrlfood establishment is outside San Joaquin County,the local health 3urisdiadon must verify <br /> current heaiih permit by signing below_ CoMmissacllltood establishmen-'t is in <br /> ©�sii4i./• E <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION! <br /> 7l18rZ0U8 "- <br />