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REGEIVED <br /> VERIFICATION ®,FpjV, MH OLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ENVIRONMENTAL HEALTH <br /> G J ftl..�ti1iJGf7 ..../ <br /> VEHICLE,INFORIV�q�TLION � <br /> Vehicle Name (DBA): J f O E ?�37� <br /> Address for Vehicle: ID_ M�� AJ ; .e <br /> Street Address City <br /> 1) License Plate#: tij O$$,5a 7 4) Year: '� (_ j <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Calor: SW//LTGFS STc C L <br /> /EHICLE O�WNE�R 1NFORMA°TION <br /> - - <br /> Name: ,� ( M A k LE 60,5 fflIlU <br /> Address of Owner: 2,00 0 '2 L C 0: C C� '25,_37LStreet A dress I 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 result in permit revocation and penalties. <br /> Signature of Vehicle CTperator Date <br /> C ;RY INFO <br /> OMRMATION <br /> 3usiness Name: uA) C- ' -5G <br /> Dwner Name: <br /> Site Address: S : U60111 , •r C L' 4 IZ d d b <br /> Street Address City <br /> 'hone: ©�) <br /> the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> :ommissary as checked below:: <br /> Liquid&solid waste disposal (tonsil washing sink <br /> (2 or 3 compartments) R/Store frozen food Vehicle wash facilities <br /> Preparation of food of&cold water for cleaningZviern)'ght <br /> et&hand washing Store refrigerated food <br /> Store dry food/su plies 1]Provide potable water par ing Adequate electrical outlets <br /> r <br /> Ii nature of Commissari Owner/Operator Date <br /> HEALTH DEPARTMENT' <br /> the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> urrent health permit by signing below. Commissary/food establishment is in � �0 i 5 <br /> ounty. ;,`p 'aW2.N <br /> ignature of County REHS Date AP 0 , 201 <br /> ENVIROW ENTAL HEALT <br /> PERMIT/SERVICES <br /> 16-017 5 of 6 fAFPU APPLICATION <br /> '2008 <br />