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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): <br /> fb^ Address for Vehicle: f Q GP <br /> Street Address Ity <br /> 1) License Plate #: 4) Year: <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> /�- Name: 4e,2 2 <br /> / \ Address of Owner: G <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 /> office may result in permit revocation and penalties. <br /> V"'X' �/_ ��- <br /> Si nature ok ehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: j� /V L ,� <br /> Owner Name: In am <br /> Site Address: r CIRgi C 9 <br /> Street Address City <br /> Phone: ( r" <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 sink <br /> (2 or 3 compartments) ❑ Store frozen food ❑ Vehicle wash facilities <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 /> _P�K'N GO ICE CREAM <br /> Imo `- ns . CARPENTER RD. <br /> Signature of Comeissa Owner/Operator Date T,;TO-LV CA 95215 <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 REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />