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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle name (DBA): TKM3 Roasting Company dba Totally Nutz <br /> Address for Vehicle: 248 W Fremont Street(Stockton Arena) Stockton,CA <br /> Street Address City <br /> 1) License Plate #: Vendor Cart,Not Vehicle 4) Year: <br /> 2) Vehicle Vin #: Vendor Cart,Not Vehicle 5) Make/Model: <br /> 3) State Decal #: Vendor Cart,Not Vehicle 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Dame: Timothy A.Goree <br /> Address of Owner: 464 Americano Way Fairfield,CA <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 /> yt 6/15/2018 <br /> Sigrkture of e Operator Date <br /> COMMISSARY INFORMATION <br /> Business Dame: Stockton Arena,SMG Managment <br /> Owner Name: City of Stockton <br /> Site Address: 248 W Fremont Street Stockton,CA <br /> Street Address City <br /> Phone: ( 209 )373-1655 <br /> I,the commissary owner, can and will provide the necessary facilities for the above mentioned vehie+e at my <br /> commissary as checked below: Cart <br /> © Liquid&solid waste disposal Utensil washing sink <br /> (2 or 3 compartments) ❑ Store frozen food ❑ Vehicle wash facilities <br /> ® Preparation of food ® Hot&cold water for cleaning ®Toilet&hand washing ❑ Store refrigerated food <br /> ®Store dry food/supplies ® Provide potable water E] Overnight parking ©Adequate electrical outlets <br /> r). f � 7- a - 15 <br /> Signature of Commissary Owner/Operator 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. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />