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Date <br />Please provide all filfonation requested. An incomplete appli <br />VEHICLE INFORMATION _ <br />Vehicle Name (DBA): \AA „i06 I At of) ie. s 7-4 <br />Address for Vehicle:611..‘14(-;t:r1-2-f-`15,- 0/1 <br />Stroot Address <br />ln may delay approval. <br />e <br />/ <br />ALSIII“.....1.10.10•WW•6011,•••••••••,I•MISMIMMINORMEN <br />IMEM••••••IMINIIINRIIINIIMOMa..W.N.I./..... <br />City <br />License Plate #: Ft-) Z S' 4) <br />Vehicle Vin #: /1/16-(10 taD8fe-v MiC 5) <br />State Decal #: 6) <br />VEHICLE OWNER INFORMATION <br />Name: DA,o /o_IL <br />Address of Owner: /S-70 CA FS'T: 5 7-(-7- <br />Year: <br />Make/Model: <br />Color: <br />/(761(,.. <br />kg!. UT( I._. <br />SEA 1(},i, (7re6A1 <br />City <br />The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br />office may 9ult in emit revocation and penalties. <br />72 <br />Business Name: <br />Owner Name: Name: <br />ST"6 cmio/ cDtcA/ <br />Site Address: _ T1,-) tryi kAa Lc ( )-1 5:3te <br />Street Address <br />Phone: (2o9 ) 7- / <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />Street Address <br />- _5-- ) <br />gn. . re of Vehicle Operator Date <br />MISSARY INFORMATION <br />City <br />ri Liquid & solid waste disposal <br />r7 Preparation of food <br />El Store dry food/supplies <br />LI Utensil washing sink <br />(2 or 3 compartments) <br />n Hot & cold water for cleaning <br />LII Provide potable water <br />El Store frozen food <br />n Toilet & hand washing <br />Ell Overnight parking <br />I -) <br />Signature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />( 'Ved I <br />LII Vehicle wash facilities <br />AlStore refrigerated food <br />LI Adequate electrical outlets <br />If the commissary/food establishment is outside San Joaquin County, the local health Juris iction must verify <br />current health permit by signing below. Commissary/food establishment is in C yt County. <br />r ( o,v • <br />Signature of County REHS <br />:HD 16-017 <br />7/18/2008 <br />5 of 6 <br />1‘11,PU APPLICATION