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:ease provide all info-mation requested. An incornnlete application may delay approval. <br /> VEHICLE INFORMATION -- -'------ <br /> ljehicla Nar;re (DBri't: ----- <br /> Address for Vehicle: 35 V n G0,94 A! <br /> Street Address citV <br /> 1) License Plate 1'#. v <br /> . _��3 S ,Z�O— ---- .� . ear: <br /> 2) Vehicle vin#: 1 Gl'1f��3�K�K;3_y�Dy5) Make/Model: - <br /> 3) State Decal#: ---- Color: - <br /> s <br /> VEHICLE_ OWNER INFORMATION <br /> Name: <br /> Address of Owmer:493,5 - V" /V <br /> t-. .. } <br /> Street Address -1 40��l�/L� C <br /> :✓ cit)r vw <br /> The mobile food facility shall operate out of a commissary and shatl report to the commissary at least once each <br /> operating day for cleaning and servicing (Ca!Code sections 114295 &'114297). If the use of the commissary is , <br /> discontinued. the parmit holder must notify this office to make the necessary changes. Failure to notify this I <br /> office may result in permit revocation and penalties. <br /> Signature of Vehicie Operator —` Cate -- <br /> COMMISSARY INFORMATION _ <br /> Business Name: I eUr <br /> . <br /> Owner Name: --- <br /> ,���--�-�--�-�-Lac►-fez._ _ l <br /> Site Address: <br /> Street Address <br /> cit" -----! <br /> Phone: (ZcO � - <br /> 1, the commissary owner. can and trill provide the necessery facilities for the above mentioned vehicle at rly I <br /> commissary as checked belo;v: <br /> ' ter S!:'J,'aS�r ! f <br /> L✓ Ll l'ty^ SC'I�^\rdagt8 SIS^ S? `'K `oS C,re frcz. TCS^ .fie(icle vvash f dli ec I <br /> �2 or 3 co:rparme�=i L-- <br /> rP�^aralion cf- o''1 '.ter` xC10'$refrigerated inn; <br /> Store drt fco- _h a I <br /> _ — T/de7u8te <br /> 'L <br /> S{ nate e OT U Jner/Operator <br /> HEALTH DEPARTMENT <br /> If the commissaryffood establishment is outside San Joaquin County, the local health jurisdiction must „erif, - <br /> current health rermit by signing below. Cor missarr!fo^d estabhsh,r.ent is ir,, <br /> County. i -- <br /> f <br /> Signature of County RENS Date { <br /> t <br />