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PIC-ase rrovide MH informaTion requesiied. An iracornpalebt application may delay ap provaH. <br /> 1� i4�C�>e <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> ! if <br /> A <br /> 1) License Elate 0: �7 ��� ` ' �F' �) Year. <br /> - <br /> ? ?) Vehicle Vin 3 5) MakeefModei: <br /> Mate Decal G) Color: <br /> uoc.euvo� vuuuuou-Mu vu cuu'Y M. <br /> Name: <br /> Address e��vvner: ✓ <br /> lac-mob!a resod facioltij shaHH opsFate on-e.a Commisseny artd Shp-HH repos to the Cor nmis -T. at @eset or oe e-I r <br /> operating day aer Gleaning and 5erT!Q9n_q (G. alGonle secUors 194205 as 114207). €f the use of ie cGMMEssary is � <br /> i discot"dldnued, 4:h e r aR holder rnust na if-y U'Dis offle@ r,1.0 Make`,,e neaeseary changes. Failure to notl5i his <br /> ofno-_may resuet in permit revocation and penaMes. s <br /> 'Signaw�e of Vehicle Operator mate <br /> r <br /> Business Name: r, <br /> Ol4/(ler Name: r— <br /> 5�ee�Addrzss C[W <br /> h@ a©sr6acSSar LWGi@C,can grad Will p�roVide tie recessa»y 9aCElities fr©ria aboves�'s3ti�raed v@F�Ilela attar <br /> Commissary as Checked tbaiomr: <br /> i = <br /> Liquid c solid waste disposal Utensil washing sink Store frozen food M 7 Vehicle wash facilities <br /> i 4 P (2 or 3 compartments) <br /> a ❑ Preparation of food Hot ix cold water for cleaning Q Toilet&hand washing 0 Store refrigerated food <br /> I <br /> ❑ Scored dry fnodlsuppi 7// 0 Provide.potable water Overnight paricing a Adequate electrical outlets <br /> Signature of Comphissary Owner/O_p � <br /> ror Date <br /> 4 <br /> j If`:e cosnmissae�rlfeod establishn-ent is offside Saes Joaquin County,the local health�uecsdiction Must Very } <br /> i Current hesitls pe M11 by Signirad beioirif. ConMlssarylfaod es'eablishment is ire <br /> l <br /> Signature Qf Count,REHS bate <br /> EHo 16-017 5 of 6 MFPU APPLICATION <br /> Tf18(200a _ <br />