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• VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> FVehicle Name (DBA): <br /> Address for Vehicle: <br /> Streetaaaress <br /> City <br /> 1) License Plate#: G7.��r' �� 4) Year. . .15�Z77 <br /> i 2) Vehicle Vin#: �rn�3S��'33D �/'S} Make/Model: 1 <br /> 3) State Decal 6) Color <br /> zx <br /> VEHICLE OWNER INFORMATION <br /> Name. <br /> Address of Owner. SCJ <br /> Street Address <br /> city <br /> The mobile rood facility shalt operate cut of a commissary and shall report:to the commissary at least once each a <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). if the use of the commissary is <br /> discontinued, the permit holder must notify this office to make the necessary changes, Failure to notify this <br /> o ice may resul i Tmit revocation and penalties. <br /> I p;Siature ofrator DaMISSARY INFORMATION <br /> ness Narrle: La Comercial Corporation <br /> Owner Name: C. R. „Chip"Arnett, Jr. z <br /> Site Address: 2900 E. Harding Way, Stockton, CA 95205 <br /> s Street Address <br /> Phone: (209 )464--4570 <br /> I I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at any <br /> cornmissanr as checked balovv: <br /> ! l <br /> i <br /> i 0 Utensil washing Liquid solid waste disposal © sink ®Store frozen food ❑( <br /> (2 or s compartments) Vehicle wash facilities t <br /> i <br /> ❑Freparation of food Pq Hot&cold water for cleaning ®Toilet&hand washing Store refrigerated food t <br /> re dry foodlsuppiies 0 Provide potable water ®Overnight parking X Adequate electrical outlets <br /> 9 <br /> Signature of Commi sary Owner/0 er Dates <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> t current health permit by signing below. ComMissary/food establishment is in <br /> county. <br /> Signature of County RENS Date <br /> EHD 16-017 <br /> 7/18/2488 'aiE MFPU APPUCAIJON <br />