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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): _NPA ICE a,66 <br /> Address for Vehicle: 3 C A Q NfE OW CPr q5A <br /> Street Address City <br /> 1) License Plate#: 1p 14,Q--:S— [0%(r, 4) Year: <br /> 2) Vehicle Vin #: )Uri=CI lr�K 7,1117( Okk C) 5) Make/Model: CMC <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: M ST <br /> Address of Owner: 512.1 WATMOD RD �'�pC i_C 85216 <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 /> M r� _ s1� (Z - <br /> Signature of V icle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: > k _0 -1----e, ' <br /> teaxL- <br /> Owner Name: <br /> Site Address: <br /> Street Address City <br /> Phone: ( f) � ��I <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) tore frozen food Vehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Store dry food/supplieess' Krovide potable water t�overnight parking `74-Adequate electrical outlets <br /> PICK'N GO TC7- <br /> 3553 E. C 7. <br /> 1-6215 <br /> Signature of Commissary Owner/Operator Date <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 />