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VERIFICa4nuN OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORIUTATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> StreetAddre3s <br /> City <br /> 1) License Plate# 'f/J�s9�5 <br /> 2) Vehicle Vin# I IV 9BSao��EFSaaao9 s) Make/Model: e <br /> i <br /> 3) State Decal#: 6) Color, p <br /> I VEiiml!®WNER INFORMATION" <br /> i Name: <br /> Address of Owner. X- <br /> 0.3 <br /> ' street Address 701 <br /> The mobile food facii' shall city <br /> KY 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& 11429n. If the <br /> use the commissary is <br /> I discontinued, the permit holder must notify this office to make the necessary changes. Failure to nossa this <br /> *o e may result in permit revocation and penalties. <br /> 11'gnatureof hicle O erator �`�— <br /> MIS.4ARY INFORMATION Date <br /> Business Name: La Comercial Corporation <br /> owner Name. G_ R."Chip"Arnett, Jr_ <br /> Site Address: 2900 E. Harding Way, Stockton, CA 95205 <br /> Phone: (209 )464-4.570 snvmaaar <br /> em clp. <br /> 1, the commissary owner,can and will provide the necess <br /> commissary as checked below facilities forthe above mentioned vehicle at my <br /> i <br /> Liquid&solid waste disposal © Utensil washing sink <br /> Bora comPerimenm) ❑Stnre frozen recd ® Vahltla wash fad6aes <br /> ❑Preparation of rood ®Hot&cold waterfor clewing, ®Toilet&hand washing E] Store refrigeratedfood <br /> Cl Sto food/supplies �provide p ie water ®Ovemight parkin <br /> f <br /> 9 ®Adequate electrical outlets <br /> Signature of Comml a Own r!0 erator —/y_ /T <br /> RT <br /> HEALT14 DEPAMENT Date <br /> If the commissary/food establishment is outside San Joaquin County,the local healthjurisdi <br /> current health permit by signing bel <br /> County. ow. CommissaWfpod establishment is in <br /> ction must verify <br /> Signature of County RENS <br /> Data <br /> 019-017 <br /> 62008 Sorb <br /> MPPUAPPU A'noN <br /> Qk <br />