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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name(DBA): �Ct �.� - •yA <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: L i� 4) Year: <br /> o <br /> 2) Vehicle Vin#: ��G `` f t aRe/Model: <br /> 3) State Decal-#: 6) Color: '. <br /> s <br /> _ <br /> �E <br /> Name: .. - r 4 V ` <br /> Address ol Owner. l j' �'� L�( �tj r 0- <br /> Street Address 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 <br /> offico may result in permit revocation qnd penalties. <br /> llf' <br /> Si nature of Vehicle Operator <br /> Date <br /> 'm5w V1I,SSA {N ORIVIA fl Fy _ 3 qt r �� F - ,� <br /> Business Name: j C. <br /> Owner Name: <br /> Site Address: <br /> Street Address city <br /> Phone: C-�ct <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> ❑ Liquid&solid waste disposal ❑ utensil washing sink Store frozen food Vehicle wash facilities <br /> (2 or 3 comparbnents) <br /> ❑Preparation of food ❑Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> ❑Store dry food/supplies ❑Provide potable water Overnight parking Adequate electrical outlets <br /> PICK'N GO ICE CREAM <br /> A)- 14'358131 E.CARPENTER RD. <br /> Signature of Com missy Owner/Operator _ Date ON,CA 95215 <br /> HEALT(t <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 <br /> County. <br /> Signature of County RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/1812008 <br />