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VERORCA u goN OF 'VEHHCLE C®Mh-WusSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> �EFIICLE�IUFORNWTIOM <br /> Vehicle Name(08A): <br /> Address for Vehicle: <br /> StreeEAddress <br /> 1) License Plate#: 4) Year. . <br /> 2) Vehicle Vin#: %741- <br /> 5) Make/Model:3) State Decal#: 6) Color. <br /> EWI ,.0ILE®WWER HNFCRIMIiATION <br /> . : l <br /> p Address of COXvner. <br /> Street Add <br /> _ Orly <br /> the mobile food facility shall operate out of a commissary and 'shelf report to the commissary at least once each <br /> III operating day for cleaning and servicing (CalCode sections 114295€114297). if the use of the commissary is. <br /> diseon " - ed, the permit holder must notinj this office to make the necessary changes, Failure to notify this � <br /> office mai result i arm urea - <br /> ties. <br /> Si ature of Ve PEgEbor <br /> 60MMISSARY W=InMRRATION Date <br /> Business Name- La Comercio) Corporation <br /> Owner Name: -G. R- ^Chip"Arnett, Jr <br /> Site Address: 2900 iz Harding Way, Stockton, CA 95205 <br /> StseatAddress <br /> Phone: (209 )464-4570 City 1 <br /> I,the commissary owner,can and will provide the necessary facilities forthe above mentioned vehicle at my <br /> commissary as checked below: <br /> ec <br /> 0 Liquid&solid waste disposal M Utensil washing sink <br /> (2m3 mmpartrnmis) ❑Store frozen rood .� Vehicle wash'rad3liae 3 <br /> ®P a ation of food ' Hof&cold waterfor cleanin <br /> 9 ®Toilet g hand washing Store reidgerated food <br /> Stor ryfnoftuppii " ProvWepowa x1OVemightparkin <br /> G d 9 n Adequate elechicai ouvais <br /> Sigrtaiure of Comm! sa Owner/00 er Date% <br /> HtALTH DEPARTMIENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdieiion muse verify <br /> i Current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County RENS <br /> Date <br /> EHO 16-017 <br /> 7H 6f2�08 3 W 6 <br /> • MFPU APPL1CAlMON <br />