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312008 5 of <br />Sionature of Corn <br />HEALTH n PPARTABENT . <br />if the commissary/food establishment is outside an Joaquin County., the local healthluitsdistion mast verity :lurrant health permit by signing below. Commis-sari/Hood esaabils13Ment is in :;:ounty. <br />3ignature of County RE-IS <br />VER1119CATIICM OF VEHICLE COMMISSARY Pie-me provide all information requested. An incornplete application may delay approval. <br />I VaNCLEMMillliATiN'-:. <br />Vehicle Name (DIM): <br />' Address for Vehicle: <br />Street Adtimc 6-a06-1 <br />License Plate #: 2ayqjzL 4) Year: <br />Vehicle Vin gr. /Ng 5- 5) ktialce/IViodel: <br />e-if 6) Color: <br />-.1f EHLOLE-0..ilfi'MRAEMF <br />Name: <br />kW Street Address :A t r ..4 <br />The rriOblie 47 cod facility shall operate out of a commissary and shall report. to the <br />commissary aFe, least onO9 eacn 1 <br />V i <br />oporating day for cleaning and servicing. (CalCode sections 114295 <br />el 1142M if the use ofthe commissary is 1 discontinued, the permit holder must notify this office to maize the necessafy changes. Failure to notify this, k office may result in per revocation and penalties. <br />; <br />• t I 0 C v 1 t. <br />E : <br />3 <br />:A. COI 100C • <br />rk -C 11 ak <br />1 <br />• <br />1.1- AA: <br /> '1 yrs.' 1-0 - Lf -5 <br />CM! <br />I. the corm-Mee-al/ owner, can and will Ovide the necess.a17 facilities for the above mentioned vehicle at my commissaly as checked below: <br />E.:1 Liquid & solid waste disposal <br />.to dry food/suppli Provide potable water' E Overnight parking Adequate electrical <br />thl Hot a cold water for cleaning El Toilet & hand washing E3 Store reerated food <br />Vehicle wash facilities <br />Outlete 4.; <br />MFPU AFPLICATIC)i,l <br />a) State Decal #: <br />//P. <br />Address of Owner: <br />5 <br />Cibr <br />erator <br />COIVENISSARY'llinailiNNIGKV: <br />Business Name: <br />Owner Name: R . <br />Site Address: 261 00 <br />StreatAddress <br />Phone: (ZO-A) L't (OM.- L't 5 1 <br />gnature of Vehicle 0 <br />1, 1-- t <br />Date <br />7 preparation of food <br />M Utensil irashing sink <br />(2 ar3 comparanants) a, El Store frozen food