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ERRMCATI©G OF VE 3I LIE COMRIAMSA, RRY <br /> Please provide all inforrnatlon reciuested. An incomplete applfaation may delay approval <br /> JEG i! 'ivE l�( G� Rf� 1 f <br /> Vehicle Marne(DBA): 19 <br /> Address for Vehicle: 4 <br /> J ' Street Address City <br /> L <br /> i <br /> 1) License s latet: �'� �' 4) Year. <br /> 2) Vehicle Vin#: ��� ,�� ����%c� ft"5) MalcelModel: � <br /> 3) State Decal t: G) Color: <br /> cLEOMN POW <br /> Name: <br /> Address oP wner: A <br /> c Street Address Cibj a <br /> n <br /> i she r nobile food facilibj shall operate out©e a commissanj and shall report to the con missary at least once each <br /> Operating day for cleaning and servicing (CalCode sections 114295 & 114297). if the use of the commissary is <br /> discon'Einued, the permit holder must nofifrj this office to make the necessary changes. Failureto noWi this <br /> office meal rc ul-npe /Fello alio and penall les. <br /> i Slgnature of Vehicle Operator Date <br /> I Business Name: <br /> Owner Nave: 'L <br /> Site Address: C " , v �-� <br /> strastAddrass —� - city <br /> Phone. V( �i <br /> (2C' ; <br /> k kM � ��, - <br /> s s,the <br /> comm, j owner,can and troill provide tlae necessanj facil"mties for the alcove mentioned vehicle at many J <br /> cocmm .issary as Checked heiow: <br /> Liquid&solid waste disposal a� Utensil washing sink c ❑Store frozen food Q <br /> (2 or 3 compartments) Vehicle wash facilities i <br /> 1 o a <br /> ❑ Preparation of food ° Hot&cold water for cleaning M Toilet&hand washing ❑ Store refrigerated food 4 <br /> ? ❑ for 'dry food/supplies Q Provide potable water Overnight paricing ) Adequate electrical outlets <br /> xY- <br /> Signature offCorriniissary Ownerl0 er Date <br /> 1 ly the commissary/food establishment is outside San Joaquin County,the,local health jurisdiction must venfij fi <br /> f curren-heakh permit icy signing belovu. Come missanjlf0001 esrablishrnent-is in <br /> ti a <br /> F 6 <br /> i <br /> Signature of Count[REHS tate <br /> ,l <br /> EHD 16-017 5 0.6 MFPU APPLICATION <br /> 7[18!2008 <br />