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Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Blame (DBA): � w <br /> Address for Vehicle: <br /> Street Address CRY <br /> l <br /> ' 'i) License Plate�r': V ,37 .:3 4) Year: G L <br /> �} Vehicle Vin#: //Ii 1 k. ' 34 5) Make/Model: - <br /> 3) State Decal : L2 h 6) Color: <br /> F <br /> L v:EEH5CmE (DUUMER WFORMA a ION i <br /> Mane: , <br /> Address of Owner: ,!' L' SSD <br /> Street Address 1 iy► a <br /> F <br /> ?hs mobile food facilibi shail operate out of a commissary and shall report to the commissary at least once each <br /> operating day Sae cleaning and servicing (CalCode sections 134295 P= 114297). if the use of the commissary is if <br /> discontinued, the peernit bolder must: notiflj this office to rnal.e the necessary changes. Failure to notlfy this <br /> office may resuit in perrrcre revocation and penalties. <br /> SignaWre of Vehicle Operator Date <br /> ��M61liI�bARY��9�6G�blt�A�'6�� <br /> Business Name: <br /> :- 10 CA"CL lC�)-.rl <br /> s Owner blame: <br /> e <br /> Oite Address: 2q 1� c � Ut1.��1 � u C�. �Tt7�f1 r�- — iL,'f <br /> Street Address —� city <br /> Phone: int("-)'A- �� 6 <br /> s "s,.jhe corninissenj owner',can and will provide ttae necessanj facilities dor the above mentioned vehicie ai my <br /> corm-nissary as checked beiow: { <br /> 0 Liquid&solid waste disposal ''' Utensil washing sink �o �Store frozen food Q Vehicle wash facilities <br /> i (2 or 3 compartments) E <br /> Preparation of food Hot&cold water for cleaning P^1 Toilet hand washing Q Store refrigerated food <br /> ❑ Stpplies Provide potable water ` Overnight parking ;� Adequate electrical outlets j <br /> G 3 <br /> Signature of Commissa Owner/Operator Date <br /> If the cor,missary1food establishment:is outside San Joaquin Oounbj,the local healUa jurisdiction must ver i�f <br /> s, current health pernit by signing below. Cora missar9ylfood establishment is in <br /> r Signature of County REHS Date <br /> a, <br /> EHD 16-017 5 of 6 MFPU APPLiCKNON <br /> 7/18/2008 <br />