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- - • - - .0 ce N., -ow mom= -Nor To, awagvna 040vIcarkevet a It A <br />Please provide all bo^rmation requested. An incomplete applir 11 may delay approval. <br />Vehicle Name (DBA): <br />Address for Vehicle: <br />,7& c D <br />S I Street Address <br />City <br />License Plate #: L.K3 (9- Al 4) Year <br />Vehicle Vin #: krrly-p32i."18 1-1.35c69 Make/Model: <br />State Decal #: 6) Color: <br /> <br />IG <br /> <br />, <br /> <br />- <br />1/1/1 Cl4{ Address of Owner: (,17( ,T)ct (-c),S ve Street Address -05(_ c0 <br />City <br />The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br />office may result in permit revocation and penalties. <br />ignature of Vehicle Operator Date <br />MISSARX NE <br />Business Name: <br />j".:DityC <br />CtcY/WV (.`-"cf)c71. 7/ / 7L(/ <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my cOmmissajy as checked below: <br />Name: Sa iCt act,YI3kVe) L <br />Owner Name: day (Le-ix!, VC'S <br />Site Address: (76, ect <br />— -Street kdriress <br />Phone: (2- <br />[21 Utensil washing sink <br />(2 or 3 compartments) <br />Preparation of food <br />Hot & cold water for cleaning <br />111 Pii-v-rde potable water <br />Signature of Commissary Owner/Operator <br />Liquid & solid waste disposal o Store frozen food <br />& hand washing <br />--- <br />Ovemight parking <br />wash facilities <br />0 axe refrigerated food <br />OM-- equate electrical outlets <br />(-q/4.5-103 <br />Date <br />rFARTMEN <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />current health permit by signing below. Commissary/food establishment is in County. <br />Signature of County RENS <br />Date <br />EHD 16-017 <br />7/18/2005 5 of 6 MFPU APPLICATION