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VERMCAMOM OF VEMCLE C©MMOSSQRY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> '[FMCLS G iEOR rATIPM <br /> i <br /> Address for Vehicle: ('®�l icy {r_ a 1rt cS31S <br /> Streett Address' city <br /> 1) License Plate#: 7 7�r 4) Year: c. Z' 1,!5—. <br /> 2) Vehicle Vin �4//�E7' L;f� 5) Make/Model: S-AYr Aif� <br /> 3) State Decal 6) Color. 4AZA&z <br /> VEHICLE'O <br /> YMC MAT€®�t <br /> I Name: <br /> Address of Owner: <br /> Streat Addrass City e <br /> i <br /> The mobile food facility shall operate out of a commissary and shall report to tate commissary at feast once each <br /> operating day for cleaning and servicing (CalCode sections 114-295 a 192257). if the use of the commissary is <br /> discontinued, the permit holder must notify this office to retake the necessary changes. Failure to notify this <br /> o dice ay result in permit ere-vocation and penalties. <br /> Si•nature of Vehicle Operator Date <br /> C�0C1fa6ifi6SSAPW GE�FE3E�fltifao id3Frf <br /> Business Name: <br /> Owner Name: <br /> Site Address: 7-900 L K '% % ' ass- 6 ti q- C } <br /> StreetAddress d city Phone- (20A) <br /> i,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> 4 Liquid&solid waste disposal Utensil washing sink <br /> r2 or 3 mmpadmeMs) Q Store frozen food }' Vehicle wash facilities <br /> ii <br /> s ❑ Preparation of food / Hot&cold water for cleaning Toilet&hand washing Q Store refrigerated food <br /> E ❑ tore d:foodlsuppli Q Provide potable water Overnight parking DU Adequate electrical outlets <br /> Signature of Copfimissary Owner/ erator Date <br /> HEAL EH DEPAi2I–ElflENT . <br /> if the commisseryifood establishment is outside San,Joaquin County,the local health jurisdiction must verify <br /> f current health permit by signing below. Commissary/food establishment is in <br /> € County. <br /> t <br /> Signature of County REHS Date <br /> P <br /> EHD 16-017 5 of 6 MFPU APPUCAMON <br /> 7/1812008 - <br />