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YERMCATMH OF VENME CONKMESSARy <br /> Please provide all informa@lon requested. An incomple€e application may delay approval <br /> Vehicle Name(DBA): <br /> Address for Vehicle: �d� <br /> • StreeYAddrzrs c l_.t i� �,�� 7 <br /> i) License Plate.: 414 V :3 e-1 7 4.) Year. ;;l,Q r` � <br /> 2) Vehicle Vin5) <br /> Make/Model-LY} <br /> i 3) State Deoai;,�,E: G) Color: <br /> f <br /> 4 Name: — <br /> �7� i <br /> Address of Owner: <br /> S£reatAddrx_s CRY <br /> 11c'mobile cod ;acildty shall©:cerate oiat of a eornMilwagy and shall report to the conmiseary at least arias each <br /> opermazing rday mr cieaning and servicing Pai0crde sections 194299 Z 9 E4,2921, if t1le use of the coasroissaiy is r <br /> diseoritinuGd, th@ permit holster r,,use is ei€r� this egice to Make the necesmy changes. t°aifsere to notiC3j Lhis. <br /> lcmfice may resWt in permit revocaidon and pena9i�es. <br /> hk-6 Z -ic/ <br /> Signature of Vehicle Operator Date <br /> Business Name: I 10 0Owner L <br /> • la's- ��. I _n•� !'tC4 � l i lC <br /> Site Address: } � �_ �',Cfdl.� <br /> Strzet Addrzss �— Gi –s. <br /> `,fife cor7mr"issafm ovdner,can`+ e� e . ' <br /> and Wily l9:'dVld@ tied-'Paw@s,.ar+ "aCFB§ele5 dQr i3ae altSPi.Ve mer:trOF3@e'd ireieiGie as^c re`slai <br /> Cok7aE'FissaijV a5 Checked b@IOW: <br /> { <br /> Q <br /> Liquid&solid waste disposal Utensil washing sink Store frozen food )' <br /> i2 ors oompaftmenSa o Vehicle wash facilities <br /> -:: ❑ Preparation of food4rov&, <br /> t cold waterfor cleaning ®Toilet t fiarid 1a�ashingQ Store refrigerated food <br /> St ed food/supplieside potabla wat r f�i Ovemi ht adcin9 P 9Adequate elech-iral outletSignature of Commis p Date <br /> I IT, NEW <br /> f the co.:nissarylfeod estahiis"nierit is outside Pare Joaquin COUn j,the Focal hea6th jue-ec iction roe rsf.verist <br /> ^4rre liEaltdi7E litJysdC�SIrGba- lol. Co mraissaryi-oodesteblisheientisin <br /> Signature of County RENS Date <br /> EHD 16.017 <br /> 7/7812008 = Soi6 <br /> MPPU APPLICA710j\1 <br />