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VERMCATOON OF VEHUCLE C ONIffiSS A Ry <br /> please provide all inforinai ion requested. An incornlalete appllcatfon may delay approval. <br /> Vehicle Name(I)BA)'. <br /> Address for Vehicle: G'U ` , . 44_ <br /> Stra�Y Addr2as city <br /> 5 �) Ucerlse Plate#: 4) Year, <br /> ! 2) Vehicle Vin 5) makelmodel: <br /> 3) State Decal; �' 6) Color: f <br /> Name: <br /> f Address Of Owner: _ <br /> 5ftastAd 7 <br /> Clift _ <br /> =c m.ohilo?o(sd facility shall BAeeate Out Of a co <br /> A�JE��filfig day a-er el�anin dE7d`a�EVi6i �y and shall fBjJOit t0 the COr�nenissary at least Once each 4 <br /> J c2g ( Iliad®sci ons 99429;, Y), if the case of the comiWIS6a�j is , <br /> dtsct�nttneaed,t[�e peril:holder must R0 i&" is Office to Mal(*the necessary changes. Failure to notitij uis <br /> Gi ice ntay result in permit revocation and penalfaes. <br /> r a <br /> Siena ►re of Vehic e0perator p <br /> z _ ~ <br /> Business Name: ; n G-�C <br /> l Owner Name: �•.�. t, 1 �t r— <br /> �- <br /> i Site Address: 7q OC) <br /> $2te@tAddre36 1 �' r► rn Lej+ <br /> i <br /> Phone.(Zeq) bi(OLA' '-[ f �� 2 = <br /> e6mMiesar-y Owner,can and will provide the necessanj racillues for the above M�ntioned vehicle at ray <br /> c©mmfssanj as checked below: L <br /> Liquid&solid waste disposal Utensil washing sink r-7 <br /> f (2or3 ca Q Store froaea food Vehicle wash facilities <br /> C6ii1p2LUnENiLG} a f <br /> ❑Preparation of food Hot card water fOr cleani <br /> R9 IXIT0119t&hand washing IQ Store refrigerated food <br /> ❑Star nj hod/supplies '` Provide po Wsrrvarer --� ®Overnight paridng Adequate eleciriczl ouHefs <br /> i <br /> ( Si na �� � <br /> g vre aF Commissa Ownerf0 a 'or DaL. <br /> EP <br /> i; <br /> If Li3e car=irnissaWfeodt establishmOnt is autssde Sart Joaquin County,the local health jtaeisdictlon must verily <br /> j Current headtt�peril t by sluning below COn.missarvdi;ood establishment is in <br /> uountij. <br /> e <br /> Signature of County RENS Date <br /> EHE 1"17 sols <br /> 7r18r2008 - MFPU APPLICKnOM <br />