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VERMC MON OF VEHQCLE C©UVUMOS:r RY <br /> Tease provide all information requested. An incomplete application may delay approval. <br /> VEE-HOLE W ORil AT.90M <br /> j Vehicle blame(DBA): ✓ � <br /> Address for Vehicle: JQe�? <br /> Street Address CRYa <br /> 1) License Plate 4: 4) Year: <br /> `=) Vehicle Vin 5) Make/Model: <br /> R 3) State Decal : G) Color: u <br /> Tante: <br /> Address of Owner: <br /> Street Address city a <br /> 'Ito rnoaile food Saciiitij shall operate out of a commissary and shall report to the can, missenj at least once each <br /> i opetat'ing day for cleaning and servicing (CalCode sections 114295 & 114297). if the use of the cor missary is <br /> $ discorianued, tha permit hoiden rnust notifij this office to make the necessenj changes. Failure to rotiflj id',is a <br /> office may result in perp,it revocation and penalties. <br /> Y <br /> f <br /> s Signature of Vehicle O eratorDate d �' <br /> Business Narne: <br /> s <br /> Owner Mane: moi, a �� ` Ps-s; ��C'� C. <br /> / � �� � _ <br /> Site Address: �. 1�(' �ci 11C� �U���; \ r , '! <br /> Street Address -� city <br /> Phone: (ji.i�- � <br /> s the com-missary owner,can. and will provide the necessarij Facilities voe the above mentioned vehicle at rnnf <br /> c©-"Irmssanv as checited below: <br /> ;J Utensil washing sink ❑ <br /> f ❑ Liquid&solid waste disposal (2 or 3 compartmerft) o Store frozen food LAIVehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning n Toilet&hand washing Q Store refrigerated food <br /> ❑ Store dry food/supplie i Provide potable water ?� Overnight parking ?� Adequate electrical outlets <br /> # Signature of Comm(ssary Owner/0 a Date <br /> i i7 the commissaizr/food establishment is outside Sara Joaquin County,the local health jurisdiction must venfj <br /> x <br /> current Health permit by signing below. Comrnissaelji ood establishment is in g <br /> i <br /> a <br /> a <br /> Signature of Count! RENS Date <br /> a <br /> EHD 16-017 5 of 6 MFPU APPLICAilON <br /> 7(18!2008 <br />