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Address for Vehicle: <br />Virif-HCLE PRFORFATION <br />Vehicle Name (MA); <br />VEHICLE OW -R:INFaRilf2ATIION- <br />Name: ,..„1'1A//1.4V <br />Address of Owner: / <br />Strut (kir= 6.4( <br />City <br />&el frdo C•-• Street Address <br />License Plate ik /ft/ 4/579 / <br />Vehicle yin <br />0:-457-Trki/2/19,04 gfe' <br />S) State- Decal #: <br />Year; <br />Color: <br />A9a <br />c\k- r-re,A <br />C-1- R. "C \r‘.t 01,. ' A( \.?"\Q-.)ri <br />I <br />2q 0 L 1-\ 0,'.ravrva. Wrkv Sc.-.",azt Address <br />Phone: (Zecl) - <br />S i. 1. 'at c,-) <br />Business Name: <br />0 wn s-r <br />Site Address: <br />VIEREIRCAlujN OF VEHICLE CONTIftSARY <br />Please provEde a?E 'informatIon requested. Ara incomplete application Mk, delay apwaval. <br />The mobile food facility sErlalE operate out st-' a commissary arid shall report to the cornmiseary iesst once sech operaticz2 dey for ciaaniag and aenlging cCeiCode seoltons 1142E6 es 1142E7). the use e the conarnisiety Es disoontinued, thepa-mit holder reitES2 aotify thEeoTioca. to make the neoessary changes. FalitEre nonj this cfRoa may restat Ira -3 it revooation and panaiffea. <br />Signature of Vehicle Operator <br />CORPSERtegARYIMPO <br />Date • - <br />L the commissary owner, can and wilE provide the necessaty facilities for the above mentioned vehicle at m-y pommies-my as ohesked belovtr: <br />Date 77. <br />51 Utensil washing sink <br />(2 ar3 commintuds) <br />Preparation of food ot & cold water for oleaninc <br />Sto dry ad/supplies Provide po <br />Sig tire of COMrTli. sary Owner/Ope <br />HEALTH brOPARTRIMETr- <br />Liquid & solid waste disposal <br />N. Toilet & hand washing <br />Overnight pricing <br />[11 Vehicle wash facilities <br />El Store refrigerated food <br />1 <br />Adequate e1ect-Ica-1 d'utet <br />op El Store frozen food <br />if the oornmissaryifood establishment Es outside San joaorain County, the local health:prier:notion must verify <br />current health permit loy signin.t3 below. Commissarylgood establishment is in County. <br />Signeture of County REE-IS <br />ENO le-017 5' of e WiFF-U AFFUCATION