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Please provide all information requested. An incomplete application may delay approval. <br /> VEMCLE:GMEE2I2ii ATIOW'- <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> StreatAddiess city <br /> `101 � aV � 1 <br /> 1) License Plate#: _f' `�i c� 4) Year. » <br /> 6 2) Vehicle Vin?P. yep C3 /U 5) Make/Model: <br /> 3) State Decal* 1�7� 6 y� G) Color: gb'4,1s".i- <br /> VEmicLE-OWNEl INFOR MM <br /> Name: <br /> Address of Owner: <br /> Street Address ck, <br /> i he mobile food facility shall operate out of a commissary and shall report to the commissary at least once each . <br /> operating day for cleaning and servicing (CalCode sections 114295 Pz 914297). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to matte the necessary changes. Failure to notify this <br /> office may result in permit revocation anndppanaltles. / <br /> Signature of Vehicle Operator Date <br /> C®IIIMIBSA12Y°G�Eok2(IP� 116 <br /> Business Name: p a�r <br /> Owner Name: <br /> Site Address: 20t 00 t,. h � CA 520 <br /> Street Address city <br /> Phone: (ZCLJJ) V1(JLA- w15 <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> !� commissary as checked below: <br /> v ® sink <br /> y Liquid&solid waste disposal Utensil washing t ❑Store frozen food Vehicle wash facilities <br /> (2 ora eampartmerrts) <br /> ❑ Preparation of food Hot&cold water for cleaning ®Toilet&hand washing ❑ Store refrigerated food <br /> I <br /> ❑S 1 dry food/supplies Q Provide potable water ?` Ovemight'p/arking Q Adequate electrical outlets <br /> Signature of Com ISee Owner/Operator Date <br /> H DEP/R-MENF <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. !� <br /> Signature of County REHS Date <br /> M1 <br /> EHO 1"17 5 ar a MFPU APPLICATION <br /> F78@O08 <br />