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VERIFICATION OF VEHICLE COMMISSARY <br /> RY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address <br /> city <br /> �) License plate#: y i)A W <br /> a <br /> 2) Vehicle Vin#: ,�Lj <br /> 4) Year: C 13 <br /> 'q(4•5oyifA % 'l,? z, 5) Make/Model: �- <br /> 3) State Decal#: <br /> + 6) <br /> Color. <br /> VEHICLE RINNER INFORMATION i <br /> iN a m e: f t. � <br /> Address of Owner. <br /> street Address <br /> ci <br /> i he mobile food facility shall operate out of a commissary and shall report to the commissary <br /> Operating day for cleaning and servicing (CalCode sections 114295 & 114297)_ If the use of the commissary ry at least once each <br /> .discontinued, the permit holder must notify this office to make the necessary chap es. F <br /> Of`ice may result in permit revocation and penalties. ry is <br /> / g ailure to notify this <br /> 1 Signature or Vehicle O erator <br /> a �5 <br /> IOEUilU113SARY INFORMA7'IQN Date <br /> Business Name: La Comercial Corporation <br /> Owner Name.- G. R. "Chip"Amett, Jr_ <br /> Site Address: 2.900 E. Harding Way, Stockton, CA 95205 <br /> Street Address <br /> Phone: (209 )464.-.570 city <br /> I, he commissary owner, can and will provide the necessary facil' • <br /> commissar r as checked below: ry hies for the above mentioned vehicle at my a <br /> j 7 v <br /> Liquid&solid waste disposal 0 Utensil washing sink <br /> (2 or compartments) ❑Store frozen food © Vehicle wash facilities <br /> ¢ry food/supplies <br /> ❑ Preparation of food 3 <br /> ®Hot&cold water for cleaning Toilet&hand washing E] Store refrigerated food <br /> Provid <br /> ❑Sr /! •Q <br /> l� potable terQ Overnight parking Adequate electrical outlets <br /> Signature of Com isse Owner/0i-rotorr. - � S <br /> Date <br /> EALTH DEPARTMENT <br /> !'the commisseryffood establishment is outside San Joaquin County,the local healt <br /> current health permit by signing below. Commissary/food establishment is in h jurisdiction must verify <br /> C0U,IIy. <br /> Signature of County REHS <br /> Date <br /> 015-017 <br /> 812008 5 of 6 <br /> rv1FPU APPLICATION <br />