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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): n}-Wmf)ilJ CE- CRt P r1 Address for Vehicle: Street Address city 1) License Plate#: 7�'6 1 4) Year: �(aQ 2) Vehicle Vin #: I G C F G I S 1831 IL1ke/Model: 9 3) State Decal #: 6) Color: VEHICLE OWNER INFORMATION Name: 1 N 6 Address of Owner: MCt410U11190k,101 N . S reet Address City TL_ _L:1_ 11iLy _1.._11 ..4_ ..L ..0.. __3 _L._II .. ....I.4— a"— —4. 1—•..moi .. i.h 1 iIC ii1V Vi1C IVVU 161.111 Ly JliGii VperG CC V--U- VI G UUMIMC).3C ty a11U OiiGll iCFUIL iV ilii. f.l.i1f I111iiJJal�i GC luaJL V:iVc cal.ii operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. I LI-I S`- Si attire of Ve icle Operator Date COMMISSARY INFORMATION Business Name: / Owner Name: Site Address: Street Address City Phone: (2 og C1 401 I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: ❑ Liquid&solid waste disposal ❑ Utensil washing sink (2 or 3 compartments) ❑ Store frozen food Vehicle wash facilities ❑ Preparation of food q Hot&cold water for cleaning--<] Toilet&hand washing Store refrigerated food ❑ Store dry food/supplies ❑ Provide potable water Overnight parking Adequate electrical outlets PICK'N GO TCE CREAM n CARPENTER RD. Signature of Comm ssa Owner/Operator Date CA 95215 HEALTH DEPARTMENT If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County REHS Date EHD 16-017 5 of 6 MFPU APPLICATION 7/18/2008