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g.44-7.r;;20-5-1 <br />License Plate #: 3Z 6 73/5- 4) Year: <br />Vehicle Vin /66(1P.g?‹.1334/G)(-2 / 5) <br />-0) State Decal #: <br />WtlL Otilfi\E-R1EMF00110010.N. . <br />Name: <br />Address of 0 er: <br />Street Addr- <br />/9?-9 <br />e <br />a <br />2 <br />J eft 9roW) <br />Make/Model: <br />Color: <br />1 <br />VEREIRCA.TliuM OF VENOC.IE CONWASSARY <br />Meese provide au information requested. An incomplete application may delay approval. <br />%%Ei-71'10'LE <br />Vehicle Name (DBA): <br />Address for Vehicle: (.7, <br />Street Acitims <br />i The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each ic <br />' operating day for cleaning and servicing (CalCode sections 114295 `ti'-4 114207). If the use of the CoginfisOpry- is discontinued, the purnit holder must notify this office to maize the necessary changes. Failure to notify this. : office r y rev:tic:II . emit revocation and p.enalties. l <br /> <br />...1 ,-,. 2 <br /> <br />AffirtAlm i <br />Sic <br />(0t-'11- t•-t 5 in <br />2q00 L.utrAN r a-k C,14--..kelin <br />C;) kr • n PVC '( \ ,) C. <br />Street Address <br /> <br />- <br />(x.1 nOc c\k‘'or, <br />, <br />City <br />i, the cominissaly owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: <br />Site Address: <br />Phone: (ZCA) <br />Business Name: <br />Owner Name: <br />erator <br />,&itgRineARY <br />of Vehicle 0 Date <br />El Liquid & solid waste disposal <br />Li Preparation of' food <br />Li St o dry food/supplies <br />Utensil washing sink <br />Et& <br />(2 0r3 comparcoterds) <br />1.4 Hot 2: cold water for cleaning <br /> Provide potable water . <br /> <br />Store frozen food 1)71 Vehicle wash facilities <br />Toilet & hand washing ri Store refrigerated food <br /> <br />E Overnight parking Adequate electrical outlets <br /> -- Signature of Corns ssarewner1Operato Date <br />PALM OPPARTMERIT <br />if the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verity <br />current health permit by signing below. Commissaryifood establishment is in COLIFIty. <br />Signature of County REHS Date- <br />EfiD 15-017 <br />711812008 5 of 6 MFPU APPLICATION!