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VERIMCAMON OF VEMCLE COMMISSARY <br /> Tease provide all info--mailon requested. An incomplete application may delay approval. <br /> MFORMAT 10N- <br /> SHIM— <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> Street Address <br /> 'i) License Plate#: v) Year: l <br /> VehicleVin=e 7 / 5) Make/Model: <br /> i ;3) State®ecai:ft,: _ 6} Color: <br /> Mame: h <br /> ' Address of Owner: <br /> Street Address 6,1nJ <br /> 17ha mobile food facility slheil operate out of a camnlissani and shall report to the commissesy et least once each <br /> c` par a"Zing day for ciear g and senricing (Calc®de sections 1142205 a 114297). 'N the use o,rhe commissary is <br /> di�f'�33iifd�3@d, he#pie holder mast rEo$iEtj this ®dice to maim rhe necessar+J changes. failure E raotltlj�: ls <br /> off��ay se �13 pestis e�socation and penalfles. <br /> Y <br /> Signature of Vehicle Operator ©ate w <br /> Business Flame: '; G�. � �Ma� +;k 0""k L�_:')C 100 Gx'C' C, <br /> Owner Name: '3 <br /> Sii:e Address: 6ADCv,�on <br /> Street Address <br /> Rhone: aloes) l A (ir LA- <br /> •she corn:missenj Owner,can and will psovieie the necessanj facilities for the above mentioned vehicle e:L W <br /> i conirilissary as Checked b9iow: <br /> Liquid c solid waste disposal +,r Utensil washing sink Store frozen food Vehicle Nash f4acilities <br /> (Z or S compartments) <br /> Preparation of fo4issary <br /> Hot R-cold water for cleaning Toilet,L hand viashing 0 Store refrigerated food -R <br /> tor ry foodlsProvide potable water Ov emight parking `}l Adecyuafe elec'aii oufletj s <br /> + - J i 5 <br /> Signature of CorlOperaror f Dae a <br /> 't- DRF APRTMEE1 <br /> i ti the cornu issanyl300d establishment is outside Sen Joaquin Cos nr y,-2-he local heal-4l jurisdiction M,met vera ry <br /> current health permit by si jc ni ng below_ Commissanjilood establishm—ent 3s'm <br /> i <br /> Signature of Count'REHS Date -- - <br /> EHD 16-017 5 of6 NIFPU APPLICATION <br /> 7f18fZ00B - <br />