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please provide all information requested. An incomplete application may delay approval. 'VEHICLE llIqFORMATIQN. Vehicle Name (DBA): Address for Vehicle: e Street Address eiv City gif LAW / AgY - Azuzzi, i, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: ll Utensil washing sink (1 Liquid & solid waste disposal AJ (2 or 3 compart-nents) Preparation of food IAI Hot 8: cold water for cleaning Store d ,) food/supplies Provide potable water Store frozen food gl Vehicle wash facilities Toilet & hand washing Store refrigerated food DL Overnight parking Adequate electrical outlets , 6 C;c4--.11-0 City - %, A. N VC)fl . 'DO D st • h t rr. I , c; 1-Ad a- , Street Address Phone: (20,A) tA., cAk - k Business Name: Site Address: Owner Name: _Li VERARCATllON OF VEHOCLE CO:,-MISSARY License Plate :4: -71 Ay 3 74 3 4) Year: Vehicle yin #: 11M 94i IEIØ1c1k51)13 5) Make/Model: State Decal #: (2 4 6) Color: \`_;7E-ig E OWNER HIMFORiviATiON e Name: if A Address of Owner: j1:2 S —Ci Street Address L3tL, 421 42)9c4tr)c--- / ty6;" 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 servicing (CalCcde sections 114295 a 114297). lf the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. 3 -- -±-7 Signature of Vehicle Operator COMMISSARY NI.FORilliATIOM Date I Signature of Commissa Owner/Operator Date E.:IPPARTIVIEMT IC the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify current heath permit by signing below_ C.,'ommissaryifood establishment is in County. Signature of County REHS Date El-ID 16-017 5 of 6 MFPU APPLICATION 77if3f2005