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License Plate #: 1-74 X V 21,2 4) Year: <br />Vehicle Vin #: 91z4le,,7,3o)--79 5) Make/Model: <br />State Decal #: CA" 6) Color: <br />Wig(L/4/e2i <br /> <br />VEHICLE OWNER NFORMATION <br />Name: <br />t Store frozen food Utensil washing sink <br />(2 or 3 compartments) <br />,••••• <br />Liquid & solid waste disposal <br />Preparation of food <br />St food/supplies <br />Hot & cold water for cleaning Toilet & hand washing <br />Provide potable water E Overnight parking <br />/r <br />Vehicle wash facilities <br />Store refrigerated food <br />Adequate electrical outlets <br />Signature of Commissary Owner/Op ator <br />i}AEALTH 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. Commissarylfood establishment is in <br />County. <br />Date <br />VERIFICATIOX OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval <br />VEHICLE ONF-ORMATION <br />r Vehicle Name (D6A): ja„e4)-0_,fj9 O_ <br />i‘6 6:0 ft <br />Address of 0 er: (&)‘ Vc; <br />Street Address <br /> <br />etz-1 <br />City <br /> <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 & 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 may resujt permit revocation and penalties. <br />/i , <br /> <br />nature 6r f Vehicle Operator Date <br />Address for Vehicle:,--)0 e, <br />Street AddressAddress <br />COMMISSARY INFORilliATION <br />Business Name: Cloc. ?cc' c‘.:k <br />Owner Name: Ca7--) R. 0 C_\(-\'k 0 ‘‘ 3 <br />Site Address: 2°OO L. wcA.,.. 6A 0 C., 1,&.. n CA Ci5t <br />Street Address 1 City <br />")h <br />Phone: (20-A) <br />i, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />Signature of County RENS Date <br />EHD 16-017 <br /> <br />5 of 6 IVIFPU APPLICATION <br />711612006