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VERIFIC TION OF VEHICLE CC 71VIISSARY
<br />Please provide all information requested. An incomplete application may delay approval.
<br />( Vehicle Name (DBA): /141M, !.5 Frijici ifrri?
<br />Address for Vehicle: b )103 6:relinati Ciiiele, 5-*'6,t11 64 1 52, y ' ) Street Address City Zip Code
<br />License Plate #: 4/ AI/04'54 4) Year: 20/1/ ,
<br />Vehicle Vin #: .1/4 1# 6- 1C12135E7orik) Make/Model: <45 &fie /20/1/ Kir/ &et."'
<br />State Decal ti: 6) Color: Vel-Mt2
<br />:.
<br />Name:iti-11/) 44eret4
<br />Address of Owner: 0/0? Lf27410,044,A 441w 64-
<br />Street Address City Zip Code
<br />The above-mentioned vehicle shall operate out of a commissary and shall report to the commissary at least
<br />once each operating day for cleaning and servicing [CURFFL 114265 & 114287]. If the use of the
<br />commissary is discontinued, the permit holder must notify this office to make the necessary changes.
<br />Failure to notify this office could result in permit revocation and penalties.
<br />. 7,1„, fi,ff-tIA— -(75 -/-
<br />Signature of Vehicl Operator Date
<br />:.-.' A.'--r-,.,' :-:.4 ' ' ' '''' ' .: ' L' "Vi:." ".:44'4'4:-A;15:1 ',!1P-1,A1 ,,,;',..',:t:',i ,v12:61i4,11.Wv:';!,-.1.! ..4..,4 Xe: .t.:-;;,;, a • Irfri!4(*1$' 4 1 •i•-r:. - • .
<br />‘Ly klUtbW... . -.limp ' - 1VIL.,:tiv-..-c -..- -;:tt';.-!- :;',N,'.445;;a '.?.,';.--.]"st4 f:;:.-4-;';'1‘0.-;:_'V!.-?'"!' -.1q::::•;:iy•,1/41-::-' :e::,....--j‘0•,::
<br />Business Name: niii; VIVK Re-3i41s1Y4'2ik
<br />Owner Name: ieSbe dr X-.'2,4-, •
<br />. , Site Address: /62:5 1A/t94 i- X:;63,-,i1,1,t Li, -tii.„. ----",- A. - 1
<br />Street Address d' J City Zip Code
<br />Phone: ( -7 -c) '.y‘, /
<br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at
<br />my commissary as checked below: , „- DIiquid & Solid waste disposal - Utensil washing sink rThStore Frozen Food . Provide ice
<br />(2 or 3 compartments)
<br />nf:reparation of Food I1ctrical I look-up 124et & Rand washing EKchiele Wash Facilities
<br />
<br />a‘e Dry Food/Supplies nfrovide potable water 6ght Parking Erct-o-re Refrigerated Food
<br />/ .
<br />
<br />/ .
<br />of Commiss r Owner/Operator Date ._Signature
<br />H.E4TH EIIATiTME , - -.,,,:_.,.. ., rZi", ...., '.i ., t- gr,V. -
<br />If the commissary/Food establishment is outside San Joaquin County, the local health jurisdiction shall
<br />verify current health permit by signing below. Food establishment/commissary is in
<br />County.
<br />Signature of County E.H.S. Date
<br />ElID 16-01-013
<br />5/12/2003
<br />MR' APPLICATION Page 8 of 8
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