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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval, <br /> 1111-�1-7BE -0W01F <br /> Vehicle Name(DBA): Liiavy\ A IC, A()Ull 1-1 <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: �ol q 4) Year: <br /> 2) Vehicle Vin#. 'V"Te;Q> 2�-j L.-53H4 V)'OV&e/Model: S--O�8 <br /> 3) State Decal-4: 6) Color: <br /> Name: ("c", 86, <br /> Address of Owner: <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 & 1,14297). 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 /> of is may esult in permit revocation and penalties. <br /> he <br /> s*'icj'natuie of Vehicle 3tor Date <br /> Business Name: V, <br /> Owner Name: <br /> Site Address: LV b S-7 c. t � -1-6 5 b k <br /> Street Address city <br /> Phone: <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> [] utensil washing sink Store frozen food Vehicle wash facilities <br /> F1 Liquid&solid waste disposal ❑ (2 or 3 compartments) <br /> F]Preparation of food Hot&cold water for cleaning� Toilet&hand washing Store refrigerated food <br /> E]Store dry food/supplies El Provide potable water ~ Overnight parking Adequate electrical outlets <br /> PICKN GO ICE CREAM <br /> E. CARPENTER RD. <br /> --�-"-"0'1<E'-'T01',T, CA 95215 <br /> Signature of Comnfrssa!y Owner/Operator Date - <br /> T <br /> EAW '� <br /> W <br /> "A -9 <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 RE HS Date <br /> I <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />