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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): <br /> Address for Vehicle: <br /> Street Address <br /> Ci <br /> 1) License Plate#: 4) Year: . <br /> 2) Vehicle Vin#: 5) Make/Model: D( -/1/ A <br /> 3) State Decal#: — 6) Color. <br /> R VEHICLE O ER INFORMATION <br /> Name: / <br /> Address of Owner: <br /> Street Address <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 (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 /> -9-112nafureOAR <br /> Icle Operator Date <br /> COMMISNFORMATION <br /> Business Name: La Comercial Corporation <br /> Owner Name: G. R_ "Chip"Arnett, Jr_ <br /> Site Address: <br /> 2900 E. Harding Way, Stockton, CA 95205 <br /> Street Address <br /> Phone: (209 )464-4570 city <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 /> � Utensil washin sink `Liquid&solid waste disposal © 9 <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 /> ❑Stor dry food/supplies Provide potable water X❑Overnight parking 0 Adequate electrical outlets <br /> ��. <br /> Signature of Commiss ry 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 <br /> 7/18/2008 5 of 6 MFPU APPLICATION <br />