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VERB CAT90N OF VEH9CLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE NFORMATIOM <br /> i Vehicle Name (DBA): I <br /> �k, 6 <br /> Address for Vehicle- <br /> 5treetAddress <br /> 1) License Plate#: o J95 1417 p <br /> 4) Year: . <br /> n <br /> 2) Vehicle Vin#:f HCl I K�-)',= 5) Make/Model: - <br /> 3) State Decal#: 6) Color. <br /> VEHICLE (DWI€ER SMF RMATIMT" x <br /> V[V <br /> Name: <br /> ,' Address of Owner: I <br /> 3a 3 r <br /> Street Adds r--7) _ <br /> O r <br /> city <br /> The mobile food facility shall operate out of a commissary and shall repo t.,tr,o...... . :�_ <br /> oiler atfng day =or�l_�.g-- --� �_ __ rt a __: ::::- 4= <br /> •� �..0 acs vwlnons •waiY a%At: 617Ce each <br /> .discontinued, the permit holder must notify this office to ma <br /> 114297). If the Ece the necessary changes. Failure to noti,of the ary 's <br /> office may result in permit revocation and penalties. �this <br /> i 3 <br /> l Signature of Vehicle'8 erator <br /> i (20MMISSARY INFORMATION Date I <br /> t <br /> Business Name: La Comercial Cpmr)ratir,ri <br /> a OWmer Name: G. R. "Chip"Rmgtt .in E <br /> � V $ <br /> Site Address: 2900 E. Harding Way, Stockton, CA 95205 <br /> Stmt Address <br /> Phone: (209 ) 46a.-A570 cify <br /> fIr :ie commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at m <br /> i comm„tissarr as checked below: 3 <br /> Y i <br /> Liquid 9 solid waste disposal ZI Utensil washing sink <br /> (2or3 compartrnen}s) ❑Store frozen food © i Vehicle wash faCiliOes <br /> ❑ P� =Son oi�food & i <br /> cold water for cleaning Toilet&hand washing 0 Store refrigerated food <br /> 1-7 tare dry foJ�/supplies �n" Provide potable grater i <br /> / Q Ovem)ght parking n Adequate electrical outlets E <br /> Signature or Corn s ' OvarferLO erato <br /> Date <br /> IEALTH DEPARtMENT <br /> If=he commissai-yJfod establishment is outside San Joaquin County,the local health jurisdiction must veri: <br /> current:health permit by signing below. Commissarylfood establshment is in Q <br /> Gguntll. 66 <br /> signature of County RENS Date <br /> 7 16-017 <br /> 312008 5 of 6 <br /> MFPU APPUCA710N <br />