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'WWvXWaanarW✓gWAF-%1i A <br /> Please provide all ip,°--natlon requested. An incomplete applic: I may delay approval, <br /> 1 ' <br /> ,_r <br /> i at9 <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> ° Street Address Cly <br /> i <br /> 1) License Platelp 4) Year. <br /> 2) Vehicle Vin0S 5 •"5) Make/Model: e` / <br /> 3) State Decal#: _ �,;, r <br /> 6) Color: <br /> OINNEiINEORMATI01�f ` ,,: ,` u n <br /> S <br /> Name• � ''e,..hSSi 'Mlt.�� ..+..i+.1.1.`2c.r..R s'IY"�-Z�'''...Fix:C� .t� ....1.�i� �f`%.�r <br /> Address of Owner. � c <br /> /1-1 � Z Ir cam/ <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 (CalCode sections 914295&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 /> office Fnafresult in permit revocation and penalties. <br /> l � � <br /> Si nature Vehicle O erator_ paw <br /> QMAiI1ShSA 1FfNl QRM�rTC� °'.` t r- x; <br /> Business Name: G <br /> Owner:Name: <br /> s � y <br /> Site Addraess: <br /> s�etiWdiess cry <br /> Phone: (Z.4 C' " . `� <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked belowr: <br /> --�� '".r�- <br /> quid&solid waste disposal I�,arensil washing sink <br /> (2 or 3 compartments) ❑Store frozen food ai chide wash facilities <br /> • reparation-of food of&cold water for deaning E15�et&hand washing Store refri Prated food <br /> su lies � <br /> "Supplies <br /> de potable water U9tiemight parking lapg;�uate electrical outlets <br /> Si nature of Commis Owner/Operator Date <br /> ME <br /> If the commissaryHood establishment is outside San Joaquin Countythe <br /> current health permit by signing below. Commissary/food establis m�nt is al health jurisdiction must verify <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 <br /> 7I1a=08 5 ofa MFPU APPLICATION <br />