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VEMCLE IliNFORMATIQM, - Vehicle Name (DBA): ,c4 1 " Address for Vehicle: 62-?ji Street Address License Plate #: X.c "2_9 4) Year: Vehicle Vin z?liq ,5) Make/Model: State Decal #: '? Cd)' .3/VJ 6) Color: City / /Ai it9k, Provide potable water VERMICATIION OF VEHOC-.E COSSARY Please provide all information requested. An incomplete application may delay approval. Hi©E 0,517MER -NFORWA1ON Name: e e' Address a' wner: g)e-71,7 Street Address /04 9'3-A‘)C-- City 7 The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and senricing (CalCode sections 114295 elz 114207). if the use of the commissary is . c.'liscontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this 1,.} office may result in perrnit revocation arid pe-nalties. ' , Signature of Vehicle Operator CzamagSSARYIINFORIICLATION .: Business Name: - L_C-)c- -00 ck-c 1/ -72( —11 Date Owner Name: Site Address: C.71,,R. " \r,C, 9 Pvc 20.0 ( 6: Street Address Phone: (2CM) ic‘ 1:5• - City 'L.A (719 -').1-1* (*. the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: Liquid & solid waste disposal Preparation of food Utensil washing sink (2 or 3 comparimerft) CIT Cr. cold water for cleaning E Store frozen food gl Vehicle wash facilities Toilet a hand washing [1 Store refrigerated food Store-dry food/supplies (../ Let- SionatUra of Commisdary Owner/Operatoi E] Overnight parking q_l e9- 1 Date Adequate electrical outlets iTALTE! DEPA.RIMENT.. if the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify current health permit by signing below. Commissarylfood establishment is in County. Signature of County REHS Date' S of 6 MFPU APPLICATION EHD 16-017 711612008