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Please provide all information requested. An incomplete application may delay approval. <br /> VI;€s °� :OV�9FOR6i(dit+�€®i19 . <br /> Vehicle Name (DBA): <br /> Address for Vehicle: vj Cr ct •. p % - C, ,7- <br /> StreatAddress V < Gfty <br /> 1� 1) LicensePlate#k: j/`/lq . 2 4) Year: <br /> ! 2) Vehicle Vin#: 1-,g,4aSC)4�J5) Make/Model: <br /> 3) State Decal#: 6) Calor. Ts <br /> F <br /> Name: <br /> Address of Owner moo?J ] <br /> streetAddraes i city <br /> he€;mobile food facility shall operate out Of a comn,tissasy and shall reportto the commissary at lams•once each <br /> operating day 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 - eesuIt' pemmit r anon and penalties. <br /> Signature of Vehicle or Data <br /> COMMISSARY RMF <br /> ORtlft� <br /> Business Name: <br /> Owner Name: <br /> Site Address: 7-900 L �� 'f d�. �j t 0- C 1 i <br /> Zv h <br /> Street Addrdss City <br /> l Phone: (ZN) <br /> the commissary owner,can and will provide the necessaryfacliities for the above mentioned vehicle at ray <br /> commissary as checked below: <br /> % Uquid&solid waste disposal Utensil washing sink t ❑Store frozen food ©' Vehicle wash facilities <br /> (2 ora it washing <br /> sink <br /> I <br /> ❑ <br /> Preparation of food Hot&cold water for cleaning ©Toilet r hand washing ❑ Store refrigerated food <br /> ❑S o)r 21y food/supplies Q Provide potable water Y�Overnight parking Adequate electrical auflets <br /> • 5 <br /> Signature of Commissa Owne era. +�' Date ' <br /> +L"E Lj EPARTME T <br /> IIf the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> f current hemith permit by signing below. Cor(rnissary/food establishment is in I <br /> Ccunti,/. gg <br /> y i <br /> Signature of County RENS Date <br /> EHD 16-017 5 of 6 MFPU APPLICAMON <br /> Al6lZ006 '. <br />