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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 /> Address for Vehicle: � C <br /> I Street Address city <br /> 1) License Plate#: 91a�'�(�_ 4) Year. . <br /> i 2) Vehicle vin#: /Od96 '5) Make/Model- <br /> 3) State Decal#: 6) Color. <br /> VEHICLE OWNER INFORMATION' <br /> Name: L uti <br /> 1 Address of Own <br /> Street Addrsss L 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 nothis <br /> I.Office result in permit revocation and penalties. tify <br /> s-_ _ <br /> Si nature of Vehicle nm erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: La Comercia) Corporation <br /> Owner Name: G. R. "Chip"Arnett, Jr. <br /> Site Address: 2900 E. Harding Way, Stockton, CA 95205 <br /> 7 Street Address City <br /> Phone: (209 )464-4570 <br /> 1,she 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 s <br /> (z or 3 comparanents) ❑Store frozen food © Vehicle wash facilities <br /> Preparation of food ®Hot&cold water for cleaning ®Toilet&hand washing [� Store refrigerated food <br /> ❑Stor L;foodlsupPlies Provide potable water ®Overnight parkin <br /> 9 Q Adequate electrical outlets <br /> Signature of Commissa Owner/0 erator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> 1 current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> s <br /> k <br /> L Signature of County REHS Date l <br /> EHO 16-017 <br /> 7/18/2008 Sof 6 MFPU APPLICATION <br />