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VERIFICATION ION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete apPlieation may delay approval. <br /> VEHICLE ENFORMAtTION <br /> Vehicle l�ian�e(DBA): <br /> i1 <br /> Address for Vehicle: ��� <br /> G&eet ddress <br /> G°Fttt v <br /> 1) License Plate#: b <br /> 4) Year. . <br /> 2) Vehicle Vin#: <br /> 5) Make/Model- G\M �3.�y X 2A-TA <br /> 3} Sate Decal to, 6) Color_ ! r <br /> Q VEHICLE OWNED INFORMT10M <br /> 1 Mame: <br /> i Address ofOwner. <br /> s` <br /> � sfreat adaress � - <br /> city <br /> 1r <br /> i he mobile food facility shall operate ort of a commissary and shall report:to tate commissary at least once each <br /> i operating day for cleaning and servicing (CalCode sections 114295 114227). if the use of the commissary is <br /> discontinued, the permit holder must notify this office to Make the necessary changes. Failrure to notiay this k <br /> '. Qi;i, ay result in permit revocation and penalties_ <br /> 5 Sig a use of V 1 0 erator <br /> t COEt(lMISSA FORT A°�tf lli Date <br /> Business Mame: <br /> La Corrrercial Corporation <br /> it Owner Marne: <br /> C .., <br /> - P. " hip"Arrrei:`�, Jr. <br /> 1 Site Address: 29001=. Harding Way, Stockton, CA 95205 <br /> sraeetAddress i <br /> Phone: (Z09 464-4570 C4 <br /> _Ile c0rnmissary owner,can and will provide the necessary facilities for the above mentioned vehicle at nay <br /> cgrsrnissarSr as checked belot.�r: <br /> i <br /> i( Liquid&solid waste disposal n Utensil washing sink <br /> p ora compartments) ❑Sime frozen food -9Vehicle wash f2dldiies <br /> �i ❑Freparation of food `1 Hot&cold water for cleaning f� Toilet&hand washin <br /> g ❑ sure refrigerated food <br /> ❑Stae dry toodlsupplies n Provide poFabfe r, ❑Overni hr parking •• <br /> h <br /> 0 Adequate electrical outlets <br /> Signature of Com issary Ownerf aEor <br /> Date <br /> I HEALTH DEPARTjwENT <br /> !f the commissaWfood establishment is outside San Joaquin Goan <br /> tythe i Current healFh Permit lay signing below. Commissaryffood establishment is eal health jurisdiction raausi verr�y p <br /> Comity. <br /> Signature of C.ountj RENS i <br /> Dale <br /> EHO 16-017 <br /> 7 M 8128QB 'of 6 MFPU APPLiCATl0N <br />