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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: �, C, S 4-o r k - y�- ci 2 1.i- Street Address city 1) License Plate#: 6 �� j 4) Year:E�L/�/ CfG�s/ 2) Vehicle Vin #: IZf' Wa5�c/C/�5) Make/Model: � a� 3) State Decal #: 6) Color: VEHICLE4OWNERIN ,.ORMATION ..� Name: (� �--h Address of Owner: q0yo Street Address City The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each 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. Sig I nature of Vehicle,45pellator Date COMMISSARY INFORMATION Business Name: �' t C K C- CR F7 d2 On Owner Name: Y14; , S' G - Site Address: 3 _S-y7 c C L=oV—, CQ0S i o C r c S Street Address city Phone: (2,cO 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 1❑ Vehicle wash facilities ❑ Preparation of food �❑ Hot&cold water for cleaning Toilet&hand washing -4� Store refrigerated food ❑Store dry food/supplies ❑Provide potable water �Overnight parking �❑Adequate electrical outlets `L=-\�PICK'N GO ICE CREAM ,3�TZS3Lr--L-111PENTER RD. Signature ofComrri' sa 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 RE HS Date EHD 16-017 5 of 6 MFPU APPLICATION 7/18/2008