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P C, <br /> VERIFICA fRON OF VEH#CLE COM441SSARy 119 -;[9-0 <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle. <br /> streeEAaaress � 5��� <br /> i CJty <br /> 1) License Plate#_ k ,? 4) Year. . <br /> 2) Vehicle Vin #: <br /> 5) Make/Model: <br /> 3) State Decal# 6) Color, <br /> l <br /> VEP- OWNER INFORMATiON � <br /> I <br /> i Name: Z <br /> Address of Owner. <br /> Street Address j <br /> ity <br /> i e mobile Food facility shall operate out of a commissary and shall report to the cosections 11 5 & mmissary at least once each <br /> !I, Operating day ,;or cleaning and servicing {CalCode 429 11 <br /> 1.di5ConEinued, the permit holder must notify this office to make the necessaryg <br /> oP`rCe;ztay result in permit revocation and penalties. �9�' if the use of the co <br /> mmissary is <br /> chap es. Failure to notify this <br /> GLo C' <br /> i Signature Of Vehicle Operator 5 1 <br /> Date � <br /> U0110MISSARY INFORMA71(5N i <br /> Business Name: La Cornercial Corporation <br /> Owner Name: G_ R. "Chip"Arnett, Jr. <br /> Siie Address: 2900 E. Harding Way, Stockton, CA 95205 <br /> I Phone: (209 )464-4570 5treetAddress <br /> City <br /> E <br /> 1, the commissary owner,can and will provide the necessary facilities,or fi3te <br /> COMMissar�r as checked below: above mentioned vehicle at my a <br /> i^I Liquid 9 solid waste disposal v <br /> Utensil washing sink <br /> (2 or3 compamnents) ❑Store frozen food ® Vehlaie wash fac,litres <br /> ❑ Preparation or food t&cold water for cleaning ®Toilet&hand washing ❑ S'tore refrigerated food <br /> ❑ Scor food/supplies Provide potable water <br /> 0 Overnight parking n Adequate electrical outlets <br /> Signa ure of Commi a OwnerlQ erator <br /> HEAL 1-i Dl= <br /> 6 MENS Date <br /> if the c0mmissarylfood establishment is outside San Joaquin County,the local health'u . <br /> cu rrent health permit by signing below. Commissarylfood establishment is in dWloUon must verify <br /> -au;lty. <br /> Sign Lure of County REHS <br /> Date <br /> 7 18-017 <br /> 312008 5 of 6 <br /> MFPU APPUCA-nON <br />