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OF VEHIP"LL COMMISSfillRy <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address 4 <br /> �4: <br /> -ess for Vehicle: <br /> ......................... L C." <br /> Strout Addross city <br /> 1) License Plate 4)_Year: <br /> 2) Vehicle Vin#: <br /> 5) Make/Model: <br /> 3) State Decal#: 6) Color: c'L-CC1 <br /> VEHICLE OWNER INFORMATION <br /> Name: z ckj'-a 0 <br /> Address of Owlic-,r: h)r <br /> 51reat AddroBs City <br /> t) OA <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating (lay 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 ay result in papilit-reyocation-and penalties. <br /> �A <br /> Si. Uture)of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> ------------- <br /> Business Name: 1-)C:%1 L L <br /> Owner Name: <br /> Site Address: <br /> - <br /> Street Address- City <br /> Phone: ()C', <br /> ' <br /> - --------- <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at illy <br /> commissary as checked below: <br /> Liquid&solid v.,aste disposal ivi-Itensil washing sink <br /> (2 or 3 compirtments) Slore frozen rood Vehicle%vasll facilities <br /> I K-lPreparmon of fco-j Hot&oold vaaterfm cleaning Toilet&hand vmshing Store refrigerated food <br /> Store dry 'L�n:_Provid.r prminble-.,rater Ovornight parking F\f� !-Adequate electrical outlets <br /> Ab <br /> u! Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside Sall JOCICIL1111 COUnty, the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. MENTAZ <br /> Nla <br /> C) <br /> Signature OTC'01111ty REHS) SVC,,c,, Wn <br /> ej\ Date 1,�LJ t Qlldnnon Warkenti,, <br /> �Q fl&f&mrZ— C') <br /> U.] 3.. <br /> EXP. ( ct Q) <br /> cc: 'Z/?_0 11 <br />