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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): H, �\ ( I A I`' NpU) C3 V1 C f C(47A 0 <br /> Address for Vehicle: 3598 r2 - N r <br /> Street Address City <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin #: 5) Make/Model: j/ C''O- D <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: ( L L—v <br /> Address of Owner: v J C <br /> Street Address City <br /> TL„ L•1. 1. "aeirate <br /> 4-. L -r :.... .-! L..11 ..44.. 4L... ; 4 1_...-4 .. .. G. <br /> i IIC IiiVVIIC IV �CGLC VUL VI avVilililiJ�Qiy CHU 3iiGll iC1.JViL LV LitC l.V1i11111i,5rly aL ...aJLoperating day ervicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, er must notify this office to make the necessary changes. Failure to notify this <br /> office may reso ation and penalties. <br /> Signature of Ve a r Date <br /> COMMISSARY INFORMATION <br /> Business Name:T P 1 C Gid C R ic <br /> Owner Name: �(} ;ry 'm S'i?ry G n/ <br /> Site Address: 3 S'4'Q'r r, e�,4aQ Ci�(TG skp S; C To a S 2-. 4' <br /> Street Address City <br /> Phone: (�),Q) qti 9 � 17 \A,01 <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 /> c,0 ICE CREAM <br /> �,TCARPENTER RU. <br /> Sig re of C m s Owner/Operator Date STOCKTON,CA 95215 <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 />