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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): Lill 21&7 <br /> Address for Vehicle: <br /> Street Address V city <br /> 1) License Plate#: <br /> 4) Year: <br /> 2) Vehicle Vin#* 5) Make/rOodel: 5P <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFQRW,�TION <br /> Name: <br /> Address I <br /> Address of Owner:, <br /> Street Address city <br /> The mobite food facility shall operate out of a commissary and shall report to the commissary at least ores each <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 /> L <br /> office may result in permit revocation and penalties. <br /> ni store of Vehicle Operator Date <br /> COMMMSSARY NIFORMEATION <br /> Business blame: La Comercial Corporation <br /> Ovi,ner Name: G4. R. "Chip" Arnett., Jr. <br /> Site Address: 2900 E. Harding Way, Stockton, CA 95205 <br /> Phone: (20rzj' )-464-45 70 Street Address city <br /> I, the commissary ovvner, can and wiii parovide the necessary facarves for the above mentioned vehicle at my I <br /> commissary as checked beiow: <br /> Liquid&solid waste disposal Utensil washing sink ❑ Store frozen food Vehicle wash facilities <br /> (tar 3 compartments) <br /> ❑Prepar ri of food <br /> Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> tore d7foodisupplie Provi 'potable water Q overnight parking ❑Adequate electrical outlets <br /> 4-e,l� <br /> Si-nature of(�'or,�missariOA!6e-rldp-erator( Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> 'L <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />