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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION WO <br /> Vehicle Name(DBA): i -V\7 ( lVh(A. K �cr L „rtrt <br /> Address for Vehicle: 3' 9 �Y r <br /> Street Address City <br /> 1) License Plate#: fa 3 g,Al; 4) Year: <br /> 2) Vehicle Vin#: 1 ifn C FCn 15%-14S41 i5 l ), Make/Model: V Ll <br /> 3) State Decal#: L 6) Color: t N r I <br /> VEHICLE OWNER L £�ORM/ ION . <br /> vim.. <br /> Name: -PA L I,. I R 51 N <br /> Address of Owner: �, t% - 3 `f S 5 5 1 L L_ <br /> Street Address City S— <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 /> office may result in permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION per . <br /> Business Name: C p <br /> Owner Name: 7'6' p }') S C <br /> Site Address: 35�' L= , C j'Z V"V T C'Iq cliS 2 <br /> Street Address City <br /> Phone: (-5.0 <br /> I,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 sinkStore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food �QHot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> ❑Store dry food/supplies ❑ Provide potable water IS40vernight parking Adequate electrical outlets <br /> -3— ` `�� ��PICK'N GO ICE CREAM <br /> ER RD. <br /> Signature of Commissa Owner/Operator Date 358 E.CARPE 95215 <br /> - 5 <br /> HEALTH DEPARTMENT <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 /> 7/18/2008 <br />