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Please provide all information requested. An incomplete application may delay approval. <br /> t ":1ri-e`n it =— In"m oRMAt:$O <br /> Vehicle Name(DBA): <br /> Address for Vehicle: ` ��9�7 � � � h <br /> Street Addreas City !, <br /> J <br /> 1) License Plaie tt / ,?9 ` ll °-) taar: <br /> 2) Vehicle Vin#: PIX_,,W-7 5) Malce/Model: <br /> t <br /> 3 State Decal ft: 6) Color: <br /> r �Y��19�Sv' •.-. PJ❑4VE�-�Il9��i'i69ff1 _ �._.. _. - <br /> ? Name_ <br /> Address of Owner: q'7� 04 OS <br /> i <br /> street Ad rets --city E <br /> 9 <br /> The anobile food facility shawl operate out of a commissary and small report to the con. missary at least once each <br /> I operating day for cleaning and se"Maing (CalCode sections 114295 Px 114297). If the use o7�he commissary is <br /> discontinued, the permit holder c ue, notify this off ice to rmake the necessarij changes. Failure to notify inti; <br /> office nt res -in nerrnii revocat"mc and penalties. <br /> Sign ture of Vehicle Operator Date <br /> VC In <br /> Business Name: (�' i `� -O�^G�:T' n <br /> Owner Name: <br /> u <br /> Site Address: N tc� , A <br /> s <br /> Street Addrss �- city <br /> Phone: <br /> I,the commissanf owner,car, and will provide the necessavf facilitiesfor the above mentioned vehicle at ray <br /> q commissary as chec&ced below: Rg <br /> Utensil washing sink c i <br /> is Liquid�:solid waste disposal Store frozen food o 1/ehicie vvash facilitie., d <br /> {2 or 3 compartments) <br /> Preparation of rood �A Hot&cold water for cleaning M Toilet&hand washing 0 Store refrigerated food <br /> ' ❑ S'bre d jry food/suppiies Provide potable nater ' O��emight parking Adequate electrical outlets <br /> r, <br /> Signature of Commissary Owner/O e f Date <br /> if the commissary/food establishment is outside San Joaquin County,the local health jurisdiction roust veefy <br /> ti <br /> current health perronit by signing below. Commissary1food estab ishmert Is in <br /> County. <br /> , <br /> i Signature of County REHS Date <br /> EHQ 15-017 5 0 6 MFPU APPUCATION <br /> 7118!2008 <br />