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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): Address for Vehicle:' ``X ° e ` �; Street Address city 1) License Plate#: S �y6 d 3 7 4) Year: 2) Vehicle Vin #:/�Ti��?�L6f�r/N�'iSy3'Z 5) Make/Model: 3) State Decal #: 6) Color: i(/'00 T� VEHICLE OWNER INFORMATION Name: S a1 G ' O � Address of Owner: 8s6 /12" &,00 1dr?1;'rt— S7-OC,�-7-0,41 U9. 91-)l 2- Street Street Address city The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating,i for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is disconti.�r{{u d, the permi Id e must notify this office to make the necessary changes. Failure to notify this officeA r !:,�A rev cation and penalties.o o4 6`7 IS i nature of Vehicle Operator Date COMMISSARY INFORMATION Business Name: P K ol Ce Owner Name: S' 7'/)/ NJ ;I-V C 1� Site Address: 1V '7� i CIT?o.N ClS' 1 Street Address city Phone: (9-,of) 01 P 04 LCQ'-- I, the commissary owner, can and will rovide the necessary facilities for the above mentioned vehicle at my commissary as checked below: ❑ Liquid&solid waste disposal ❑ utensil washing sink ❑ Store frozen food Vehicle wash facilities (2 or 3 compartments) ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing "�u Store refrigerated food ❑ Store dry food/supplies ❑ Provide potable water Overnight parking Adequate electrical outlets -L--=-''N GO TCE CREAM -3 `� 1' '_ CARPENTER RD. Signature of Commi lary Owner/Operator Date ,.,C:LTOiV,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