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Please provide allinformation requested. An incomplete application may delay approval. E 0 t rf 4rtif-Xii4Weik • ' • 'elide Name (DBA): 7d ea EY d.-: bigi a() ,ddress for Vehicle: I Fj/ S -.S4 A Si- /,d2 Ci Street Address City Zip Code 1) License Plate #: (267.? V 2/ 1) Year: i Vehicle Vin #: /1-,071,7,2 k 027?pyy Make/Model: 6- State Decal #: 6) Color: - ., 'ame: IS C. d .ddress of Owner:/I. / ' / il ' 14 )Z Street Address City Zip Code he above-mentioned vehicle shall operate out of a commissary and shall report to the commissary at least ace each operating day for cleaning and servicing [CURFFL 114265,& 114287]. If the use of the minium is discontinued, the permit holder must notify this office to make the necessary changes. allure to notify this office could result in permit revocation and penalties. t) P--- //- c-C) — / u..ture of Vehicle O. - rator Date qTr,. , usiness Name: ,, j-,' 6 ( .ei-iy-viSlr&7- - 6,) . wner Name: 6,4 "44 r lA e e z- ite Address: g ) / f: S.-GC,' /v / ) .171-- 176 CI .'1--1 . Street Address City Zip Code aone: ( )-00 ; 3' IF; i 2.1 the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at ly commissary as checked below: id Liquid & Solid waste disposal Utensil washing sink Store Frozen Food 0-Provide ice (2 or 3 compartments) ] Preparation of Food I -Z Electrical Hook-up Toilet & Hand washing SZI Vehicle Wash Facilities ] Store Dry Food/Supplies '0 Provide potable water / i Overnight Parking Store Refrigerated Food 1. . - ture of Conmuss: Owner/6 ,, or Date . . u: t, i j: - :.N., 0 a- :',4.1:-, 7.‘rf the commissary/Food establishment is outside San Joaquin County, the local health jurisdiction shall Drify current health permit by signing below. Food establishment/commissary is in County. ignature of County E.H.S. Date -, 3-1D 16-01-013 Page 8 of 8 MFF APPLICATION /12/2003