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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE IN.FORMATM - <br /> Vehicle <br /> T IOVehicle Name(DBA): <br /> Address for Vehicle: b,C, �� �(' �(���i C D b <br /> Street Address City <br /> 1) License Plate#: ��1 7 �� j 4) Year: 4%/ <br /> 2) Vehicle Vin#: ( �j �' f � �l;i j E )? ) Make/Model: ��¢ <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> _. <br /> Name: J rI AVAII if MIMV !A <br /> Address of Owner: a UI V('/ �Y M <br /> , t! S I SST 0( f('I 01 W ( - <br /> Street Address 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 (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 /> c.... �� 1 <br /> Signature of Vehicle Operator Date <br /> _ R'►�INFOFZMATION��.--'� _-.:, -� -:�_:�� _ �- ��. � - - _ <br /> Business Name: <br /> Owner Name: S ✓Y ,,� S.�u <br /> Site Address: j s (7'r-) <br /> S%c CG 7-6�, S <br /> Street Address City <br /> Phone: (D)l ) Gi : _ (r <br /> I,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 Vehicle wash facilities <br /> Store frozen food <br /> (2 or 3 compartments) <br /> ❑Preparation of food Hot&cold water for cleaning Toilet&hand washing �❑ Store refrigerated food <br /> ❑Store dry food/supplies ❑Provide potable water '---�vemight parking \ Adequate electrical outlets <br /> PICT'-'N GO ICE CREAM <br /> Signature of Commi sa Date Owner/Operator erator — �ry-rA ='E R 15 <br /> NTE <br /> I' 1STG1�T,CA 95215 <br /> If the commissary/food establishment is outside San Joaquin County,the local health.jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County RE HS Date <br /> EHD 16-017 5 of 6 <br /> 7/18/2008 MFPU APPLICATION <br />