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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): / <br /> Address for Vehicle: �Q� f _ <br /> Street Address <br /> ty <br /> 1) License Plate#: L6�z/ 4) Year. . <br /> 2) Vehicle Vin#: Q33 5) Make/Model: s ' <br /> 3) State Decal#: - 6) Color ' <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> J <br /> I Address o wner. l� <br /> Street Address /J d 0 <br /> city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> th <br /> operating day for cleaning and servicing (CaICOde sections 114295 & 114297). If the use of e commissary is <br /> discontinued, the permit holder must notify this office to make the necessary chanesF <br /> office may result in permit revocation and penalties. g , ailure to notify this* <br /> l 171 el!y e17 -� <br /> Si nature of Vehicle O erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: La Comercial Corporation <br /> Owner Name: G. R. "Chip"Amett, Jr. <br /> Site Address: 2900 E. Harding Way, Stockton, CA 95205 <br /> dd <br /> Phone: (209 )464-4570 Street Aress city <br /> 1,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 ® Utensi(washing sink OL <br /> rt or 3 compartments) ❑Store frozen food © vehicle wash facilities <br /> ❑Preparation of food ]Hot&cold water for cleaning ®Toilet&hand washing ❑ Store refrigerated food <br /> ❑Stor dry foodlsupplies / ©Provide potable water nx Overnight parking XD Adequate electrical outlets <br /> Signature of Comm' sa Owner/0e for Date, <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 <br /> 7/18/2008 5 of 6 MFPU APPLICATION <br />