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VERIFICATRON OF VEHICLE C®MMISSARy <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name(DBA): <br /> Address for Vehicle: �9Q <br /> t' T— <br /> StaeetAddress S,r�iQ S <br /> 1(11 <br /> 1) License Plate#: �7y_ k % 4) Year. . <br /> 2) Vehicle Vin# /6Q>L/ 1a Make/Model: <br /> 1 3) State Decal#: -t 6) Color <br /> VEHICLE OWNER BNFORIIIIAT10N <br /> Name: L - <br /> Address of ner- 5 IV p[— n <br /> 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 tcaleode sections 114295 8: 114297). If the use of the commissary is <br /> discon ed, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office ria result! erm voce "oa end pa ties. <br /> Date 7 <br />• � Si ature of Ve rotor Date <br /> OMMISSARY INFORMATION <br /> Business Name: La Comercial Corporation <br /> Owner Name: G. R_ "Chip"Arnett, Jr. <br /> q Site Address: 2900 E_ Harding Way, Stockton, CA 95205 <br /> street address <br /> Phone: (209 )464-4570 city <br /> 1,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 disposal ® Utensil washing sink s <br /> (zora compartments) ❑Store frozen food © Vehicle wash facilities <br /> ❑Pr -ara)ion of food Hot&cold water for cleaning « Tollet&hand washin <br /> 1�I 9 ❑ Store refrigerated food <br /> Stork dry foodlsuppli " Provide po wat XX Overnight parkin <br /> 9 Q Adequate electrical outlets <br /> 7 <br /> Signature of Commi sary Owner/d a Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> Current health Permit by signing below. CommiSMWfood establishment is in <br /> county. <br /> Signature of County REHS Date - <br /> EHD 16-017 <br /> 7/18/2088 Bois <br /> MFPU APPLICATION <br />