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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):L - C <br /> oly <br /> Address for Vehicle: c-" f <br /> A- <br /> S tAddress <br /> My <br /> 1) License Plate#: S �� 3�� <br /> i �� 4) Year: . � <br /> 2) Vehicle Vin#: /C P <br /> M ..35� 5) Make/Model: <br /> 3) State Decal#: ?74 6 Color 9 <br /> 'VEHICLE OWNER 119FORMATIO <br /> Name: <br /> Address of Owner: <br /> Street Address ,✓ S <br /> ity <br /> i he mobile food facility shall operate out of a commissary and shall report to the <br /> Operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary <br /> commissary at feast once each <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> of;ice may result in permit revocation and penalties. is <br /> f y s <br /> Signature or Vehicle O erator <br /> COMMISSARY INFORMATION Date <br /> Business Name: La Comercial Corporation <br /> Owner Name: G. R. "Chip"Amett, Jr. <br /> q Site Address: 2900 E. Harding Way, Stockton, CA 95205 <br /> Street Address <br /> Phone: (209 )464-4570 city, <br /> I, the commissary owner, can and will provide the necessary facilities f -11 <br /> commissary as checked below: or the above mentioned vehicle at my <br /> � <br /> Liquid&solid waste disposal I Utensil washing sink <br /> (2 or 3 compartments) ❑Store frozen food <br /> © Vehicle wash facilities <br /> ❑ Preparation of food ®Hot&cold water or cleaning fg ®Toilet&hand washing El Store refrigerated food <br /> St e ry food/supplies Provide7rpotle water� �Overnight parking Adequate electrical outlets <br /> Signature of Co issa Owner/O eraor <br /> HEALTH DEPARTMENT Date <br /> n <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 i <br /> Co u nt<j. <br /> Signature of County REHS <br /> Date <br /> D 16-a» <br /> 8/2008 5 of 6 <br /> MFPU APPLICATION <br />