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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): C o\ G1 ion 16e- Crenni <br /> Address for Vehicle: �7S-S 2ctln <br /> Street Address city <br /> 1) License Plate#: CGS 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: L-a /t/ <br /> Address of Owner: 7-7 S 3 C,y�n /r s4rc J<4p <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. (� 1 <br /> Sinehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: L c o c 7 C C-p,N/ <br /> Owner Name: �fJ r1i rn S-,y <br /> Site Address: 3 s FV s CK-7-rsty qqr <br /> Street Address city <br /> Phone: (2r,`l) ct vt 4-- r-? <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 /> ❑ Liquid&solid waste disposal ❑ Utensil washing sink ��Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food ❑ Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> ❑ Store dry food/supplies ❑ Provide potable water Overnight parking Adequate electrical outlets <br /> g ��� 3588EPICK CARPENTER RD. <br /> Signature of Commisgft Owner/Operator Date STOCKTON,CA 9,15915 <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 />