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VERORCATOOM OF VEHQCLE C®M OSISARY <br /> Please provide ail inforinaliion guested. An incomplete application may delay approval. <br /> vehicie Name(Dm; <br /> 12-4 <br /> [Address for Vehicle: � 1 <br /> 0`911 �• lid �SaD S - <br /> StraetA$dt�ess Glty <br /> a <br /> i=icense Prate#: 4) Year. _ a <br /> I 2) Vehicle Vin 4: /'�l 5 d d S) Maiceftodel: �] <br /> { 3) State Desai:ft: 6 <br /> Color. <br /> - <br /> 7M.- - <br /> ,mob <br /> s <br /> Name: <br /> Address at Ow r. A 77 S', D <br /> streatAFidrem 14 <br /> >c-mobile b0d fae"W shall operata out a a cor nr f=wy and shali report to the comnfosawat least once,each <br /> 29e fts day for ctganfrrg and ®Ni61rii {Cale®do 6F�QFis �9�°� 114207). If the use of the c mmisss�is <br /> ldlsoorazlrit�ed,the (0ewlt"aider must 9202ihj this MOO to make the necessary changes. Failure to no*his <br /> QirfCe Miff rezuk 43 permit eevoca`aon and penalties. <br /> S <br /> F if <br /> /- /-/- <br /> Si nacre of Vehicle Dail <br /> Business Name: . - <br /> Owner Name_ 1 , <br /> ��. <br /> , Site Acidness: C _ <br /> 5i;88�AddrdSS � ilJ i5 C'_ kt�;� CA <br /> A <br /> Rhone- (Zcg) 'At(0,A_ lrt 5—z �► <br /> i Ehe d0m-Missagf owner,can and wili provide the nesessaW�ci6ties for the above m9no©ned vehicle aE rev <br /> c©mmi55atY as GheGked below: 1 5 <br /> i y> <br /> s <br /> Liquid&solid waste disposal Utensil wasWn+g sink <br /> {�or3 Camgarimeuts} aa Q Store frozen food Vetricle wastrracilities <br /> I <br /> Q Preparation o"'Juu ' <br /> [�Hot&cold water for clearima I(Tolet&hand w�� Q Stora refrigerated mod <br /> Q r dry fnodlsuppli, Provide le waferv t <br /> " Overnight parking Adequate electrical 61r8ets <br /> /J I € <br /> Signature of <br /> Co i Own_erfQ r Date <br /> LT <br /> - - _ <br /> r the conMissaryX006 establishment is outside Sart Joaquin County,the local health jurisdiction must verify 1 <br /> c4rrersiL hea7'th per&W!E fay signing belQW COMMissaryfaod esecablishment is i,- <br /> CounV1 . <br /> - s <br /> Signature of Couniy RENS Date i <br /> EtiD 16-0'!7 Suffi <br /> i 118f20�e WPU APPLiCATIOM <br />