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VERIFICA'T&)N OF VEHICLE CON�IISSARY <br /> Please provide all informat n requested. An incomplete applica E n may delay approval. <br /> Vehicle Name (DBA): S „� �{ ,D, ,p C <br /> Address for Vehicle: 3 �� �, C �� _ ,✓� � ,,/ �Sz�S`' <br /> Street Address City Zip <br /> 1) License Plate #: ?j �j �(� 4) Year: <br /> 2) Vehicle Vin � A�j,�15, , Make/Model: <br /> 3) State Decal #: 6) Color: Lo <br /> 2: 11"NNOWNNOW <br /> Name:.,. �A,a-P m� - - ' <br /> Address of Owner: ( C A FQV <br /> Street Address City Zip <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least <br /> once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of <br /> the commissar}, is discontinued, the permit holder must notify this office to make the necessary changes. <br /> Fa' re to notify this off a may result in permit revocation and penalties. <br /> 0. <br /> Signature of Vehicle Operator Date <br /> Business Name: P I C 1 ,� C= 14 <br /> Owner Name: <br /> Site Address: C' , 3c J-V 7-e--R T S %e lX & ✓ C <br /> Street Address City Zip <br /> Phone:(5(.4 Clot j 7 Lic <br /> I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at <br /> my commissary as checked below: <br /> ❑ Liquid&solid waste ❑ Utensil washing sink <br /> Store frozen food �❑Vehicle wash facilities <br /> disposal (2 or 3 compartments) <br /> ❑Preparation of food ''� Hot&cold water for cleaning "Ea Toilet&hand washing Store refrigerated food <br /> ❑ Store dry food/supplies ❑ Provide potable water Overnight parking Adequate electrical outlets <br /> PICK TT GO ICE CREAM <br /> 3588 E.CARPENTER RD. <br /> STOCKTON,CA 95215 <br /> Signature of Commissary Owner/Operator Date <br /> If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must <br /> verify current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County R.E.H.S. Date <br /> EHD 16-013 Page 8 of 9 MFF APPLICATION <br /> 8/17/2007 <br />