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&?_da2,7- /th6,, <br />(// 14-/----) 9619‘)t- <br />-- City <br />VEHICLE INFORMATION <br />1 <br /> Vehicle Name (DBA): -3‘ <br />Address for Vehicle: 9-49 <br />Sb-eet Address <br />(6.kQ;) X 21-k <br />License Plate #: 4) Year:. <br />Vehicle Vin #: n 5 5) Make/Model: <br />State Decal #: 442- I c"-k 6) Color: <br />VEHICLE OWNER INFORMATION <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />Ces, at62.:A 6 <br />City . <br />, The mobile food facility shall operate out of a commissary and shall report to the commissary at least once 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 1 offi ay result in permit revocation and penalties. <br />1 <br />Name: <br />Address of Owner: <br />Street Address <br />r—v ry ILL, Liquid & solid waste disposal <br />El Preparation of food <br />El sm. e dry food/supplies <br />{:} Utensil washing sink <br />(z or 3 compartments) <br />IE Hot & cold water for cleaning <br />Provide potable <br />a <br />Date <br />FORMATION <br />La Comerciai Corporation <br />G. R. "Chip" Arnett, Jr. <br />2900 E.. Harding Way, Stockton, CA 95205 <br />Phone: (209 ) 464-4570 <br />Street Address <br />City <br />1 <br /> I I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: <br />Sig ure of V <br />COMMISSA <br />Business Name: <br />Owner Name: <br />Site Address: <br />Operator <br />Store frozen food <br />igj Toilet & hand washing <br />Ell Overnight parking <br />El Vehicle wash facilities <br />El Store refrigerated food <br />El Adequate electrical outlets <br />Signature of Corn issary Owner/ ator Date, HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify current health permit by signing below. Commissarylfood establishment is in 1 County. <br />1 Signature of County RENS Date <br />Cl-ID 16-017 <br />7/18/2008 5 of 6 MFPU APPLICATION