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"VERIFICATION OF VEMCLE CONI ISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): -7 <br /> Address for Vehicle: ':�3'5e-LO <br /> Street Address City <br /> 1) License Plate#: � .-D c Sri 4) Year: !C� <br /> ) EcR D2 Vehicle Vin Y T l=' L `PA , <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: 9) P'T <br /> Address of Owner: L'�c' M c'N nU ilkq* <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 /> I office may result in permit revocation and penalties. <br /> ISignature of'vehicleTaperator Date a <br /> COMMISSARY INFORMATION <br /> Business Name: Pli r ie _ a, <br /> Owner Name: < -T N A ;r0(.ti 'a; <br /> Site Address: ^ AP fi I*i > ' <br /> Street Address Ctty <br /> Phone: W — ] :� 1:1 C <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 Store frozen food ❑ Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food Hot&cold water for cleaningToilet&hand washin Store refrigerated food <br /> \ Overnight parking Adequate electrical outlets <br /> ❑ Store dry food/supplies Provide potable water ❑ 9 p 9 <br /> PICK N GO ICE CREAM <br /> 3588 E. CARPENTER RD. <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissaryffood 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 /> i Signature of Count;/ RENS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />