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VERIFICATION OF VEHRCLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE WFORMATiON l Vehicle Name (DBA): + Address for Vehicle. _ l os- street Address city 1) License Plate#: 312-13�� 3 4 Year: . a 2) Vehicle Vin##: 5) Make/Model: 3) State Decal#: ; 6) Color , i V'EH.ICLE OWNER INFORMATION � Name: C y Address of Owner: ` Street Address _ Ci - 7 he mobile food facility shall operate out of a commissary and shall report to the commissary operating day for cleaningand ' servicing (CalCode sections '194295 & 114,297). if the ease of at elcommissary is .dt5continued, the permit holder must notify this office to ma Office may result in permit revocation and penalties. ke the necessary changes. Failure to notify his l Signature of Vehicle Operator t COMMISSARY INFORMATION Date I Business Name: La COMercial Corporation Owner Name: G_ R_ "Chip"Arnett, Jr_ Site Address: 2900 E. Harding Way, Stockton, CA 95205 street Address l Pho le: (209 )464-4570 city i, :he commissary owner,can and will provide the necessary facilities for the above mentioned vehicle I corrtnissarY as checked below: cleat my a 1Liquid&solid waste disposal " g ❑ Utensil washing sink (2 or 3 compartrnen>s) ❑Store frozen food © Vehicie wash facilities ❑ Preparation of rood3 of&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food S' re dry food/supplies " Provide po le water ❑ 0 Overnight parking n Adequate electrical outlets I Signature of Comm- sary Owner/O erator - 3 �S MEALTH DEPAR 6 MENT Date 1 tI the cammissary/food establishment is outside San Joaquin County,the local health 'urisdictio current health permit by sighing below. Commissary/food establishment is in i n must verify Signature of County REHS Date ---------------- O 16-017 Bl2�o8 5 of 6 rv1FPU APPLICATION