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1 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): G�CL//t_li1 <br /> Address for Vehicle: P �Ozd <br /> Street Address <br /> City <br /> 1) License Plate#: 4) Year: . O'(ppa <br /> 2) Vehicle Vin#: &9/}e 5) Make/Model: <br /> 3) State Decal#: Cwt t 6) Color. <br /> VEHICLE O. ER INFORMATION <br /> Name: <br /> Address of Owner: 37j9'7 NgwC Sa1�� <br /> Street Address ty, <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 /> 'Si nature of V hlcle Operator <br /> Date <br /> COMMISSARY INFORMATION <br /> Business Name: La Comercio! Corporation <br /> Owner Name: G. R. "Chip"Amett, Jr. <br /> Site Address: 2900 E. Harding Way, Stockton, CA 95205 <br /> Street Address City <br /> Phone: (209 )464-4570 <br /> i <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehiclIfood <br /> commissary as checked below: <br /> Liquid&solid waste disposal © Utensil washing sink <br /> (z or 3 compartments) ❑Store frozen rood © Vehicle wash <br /> ❑Preparation of food ®Hot&cold water for cleaning ®Toilet&hand washing ❑ Store refrigera <br /> ❑Sto dry foodlsupplies ©Provide potable water X <br /> ❑Overnight parking Q Adequate electrical outlets <br /> r <br /> ature of Commissa Owner/O erar Date <br /> ALTH DEPARTMENT commissary/food establishment is outside Sao Joaquin County,the local health jurisdiction must verify <br /> ent health permit by signing below. Commissary/food establishment is innty. <br /> Signature of County-RE-HS Date <br /> EHD 16-017 <br /> 7/1812008 5 of 6 MFPU APPUCA710N <br />