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101 <br />Year: <br />Make/Model: <br />Color: <br />dry fond/supplies ProVide potable water ZI Overnight parking <br />,ta <br />a . <br />signature Of Gommissary Owner/Opera <br />bffPARTIVEMT. '• <br />Date <br />—/—/, <br />Date Ot <br />RECENED <br />VER11FOCAMION OF VEHOCLE COM llssARy JUN 2 8 2016 <br />Please pmvide a informafrion requested. An incompleb. application may delay appre4 ommENTAL HEALTH <br /> FP.C7:11,1_11747774S <br />Vehicle Name (MA): <br />Aeg— <br />Address for Vehicle: e LklaA.ol-44..er 4 <br />Strzat Address <br />Ligenze Hetet 57/ 7 le 2O 4) <br />Vehicle Vin JGDF(Pg,i536-V 5) <br />Stat?- Dem/ #: 625-64 6) <br />Name: <br />VISHOLg OWN@R:liErRfaiMbH- <br />, E.: , (...- / Street Address i <br />i The mobile food facility shall operate out of a COMmiseary arid shall rapciiI to the contrigary at least onceeaota ) <br />operating day for cleaning and zervicing (CMGede teetima /ii.oes & l'i 4'227). if thz.', use of the oodurgiSSOry is I <br />discontinued, tine pe-nrnit holder must notify this otifte to nteke the necessary changes. Failure ito nordify thisi <br />2ci 00 ea, . 5-to c(,-Vori <br />c\A <br />Pkime4s---k <br />'atm et Add nms Cj <br />C-A 510 Phone: (2C) <br />the commissary owner, can and provide the necessary faciaiss for thG above raengoned vehicle at my <br />commissary as checked befoul': <br />Liquid & solid waste disposal 1"; Utensil washin sink El Store frozen food (2. or 3 compurtreentz) Vehicle wash facilWes, <br />N Hat & cold water for ctOortin Ij Toilet & bend \washing [:3 Store refrigerated food <br />ED Adequate electrical oistle <br />- <br />1 <br />If the oorrarnissetTifood e.ststotishment is outside Sart Joaquin County, the boost health, Priediotiort must verify <br />current health pes-mit by signing below. C>ornrilissesylfood establishment is in <br />urri:y. <br />Signature of County REHS <br /> <br />Dst <br />Etict 1i7 5 c5 FU APPLICATION <br />TnerZan <br />Address of °timer: j( /74 &-i_-66/ <br />ciey <br />office may result in permit revocation arid panel:les. <br />5.1 q//1 5 zs 4 <br />Sionature of Vehicle Operator <br />COMMISAARY-iiilFeRIVATfd <br />Business Name: <br />Owner Name: <br />Site Address: <br />Preparation of food <br />Received Time Jun, 28. 2016 1:50PM No. 0924