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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. 1/EHICLE INFORMATION Vehicle Name (DBA): �S Address for Vehicle: Street Address 61911 City t) License Plate#: 4) Year. . 2) Vehicle Vin#: /GC H 14.3/=331/v 5) Make/Model: 3) State Decal#: L,-A 6) Color. VEHICLE OWNER INFORMATION Name: j Address of Owner. I Street Address q The mobile food facility shall operate out of a commissary and shalt report to the commissary at least once each operating day for cleaning and servicing(CalCode sections 114295& 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office/rpay �result n permit revocation and penalties. C /,Lim J.y[� Signature of Vehicle Operator Date a �OMMfSSARY PNFORMATION Business Name: La Comercial Corporation Owner Name: G. R. "Chip"Amett, Jr. i Site Address: 2900 E_ Harding Way, Stockton, CA 95205 Street Address city Phone: (209 )464-4570 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: Liquid&solid waste disposal ZJ Utensil washing sink e 9 (2 ora compartments) ❑Stere frozen fend © Vehicle wash Aacilities t! ❑Preparation of food ®Hot&cold water for cleaning 7\1 Toilet&hand washing ❑ Store refrigerated food ❑Sto dry food/supplies Q Provide potable ter MX Overnight parking Q gtlequate electrical outlets Signature of Commissary Own er/Opfttor Date,- HEALTH ate,HEALTH DEPARTMENT -------------------- tf the commissarylfood establishment is outside San Joaquin County,the local health jurisdiction must verify i current health permit by signing below. Commisearylfood establishment is in County. Signature of County REHS Date EHD 16-017 5at6 711812OU8 MFPU APPLICATION