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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): �'�0 e o ( \� ecw�r <br /> Address for Vehicle: ;2.y q0 n; ✓ c v c s oc- K <br /> Street Address City <br /> 1) License Plate#: 4) Year: god t <br /> 2) Vehicle Vin #: j Lq 'r scp S (-v c 1,-4_} 1 C Make/Model: 1_A r ; <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: \ r <br /> Address of Owner: b 14" C111 y , l� i <br /> Street Address 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 Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: CP,tLjRWI,& C/N-TQ�I�A, FWD Sc vt G 0 ' [pft <br /> Owner Name: }.J� <br /> Site Address: So(-k o <br /> Street Address City <br /> Phone: <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 /> QZiquid&solid waste disposal ❑ Utensil washing sink <br /> (2 or 3 compartments) R/Store frozen food Vehicle wash facilities <br /> ❑ Preparation of food LHot&cold water for cleaning ff/Toilet&handwash' — Store-refri erated-food-- <br /> C; LI ;� Cti(�E Fc{I�lC <br /> Store dry food/supplies <br /> Wprovide potable water ❑Overnightrspr"�� 6d 8 1Ia�ts <br /> / 2440 S.AIRPORT WAY <br /> C `�,,q,�j j ✓1, I ����STOCKTON, CA 95206 <br /> Signature of Commissary Owner/Operator Date __ . . Esc 9000---- <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />