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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE <br /> Vehicle Name(DBA): r H C /�/ .j C, L R N� <br /> Address for Vehicle:3S 99 C0V -/k"'TF LI CA ?) <br /> Street Address city <br /> 1) License Plate#: �' Z 3 �� 4) Year: /� 27 <br /> 2) Vehicle Vin#: C1 R'ViP 5) Make/Model: <br /> 3) State Decal #: 6) Color: veil <br /> VEHICLE_OWNER INFORM 'TION r <br /> Name: S iz -J `IIT' il C➢ - <br /> Address of Owner: ) "2 L - /V\ 103 11 V C STCi"TL) <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 /> -S9�.l iE La L6z .SekIso G- 1 " --2c IU <br /> Signature of Vehicle Operator Date <br /> OMMISSAR'>r;INFORMT{ON x�a x � ,�: _ s . ateZ 500 <br /> Business Name: P, C N C p 4c2: cq G A M <br /> Owner Name: -S-'A' T N/-17 q / <br /> Site Address: 3S �- C i z c o Al �� Ski <br /> Street Address city <br /> Phone: (.'�°q) <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 disposa Utensil washing sink Store frozen food �jVehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food �Q Hot&cold water for cleaningToilet&hand washing Store refrigerated food <br /> ❑Store dry food/supplies ❑Provide potable water \�Overnight parking Adequate electrical outlets <br /> y� 3 _ �`\ PICK'N GO ICE CREAM <br /> ' ! — ,Y�o '���n.,r n n p <br /> - - CAR_ENTER RD. <br /> Signature ofCo m ssa Owner/Operator Date 7, CA 95215.--,-,. ..c .�,, .-�-a a i� s �y 6'r.— � c$-..z. ,�. �- -t.�sax. 'ss, �'S�'C."'�`4'2"l`,.• <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 RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />