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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEEbHIO M. <br />_. <br />, <br />/t--) ---; -, 4 r, a, Vehicle Name (DBA). <br />- \--€... 1 on Ls'pre.)c,- hc) . , <br />Address for Vehicle: Ra \ k C) ap_e_Aropc. 'TR \,„, V1 den(=-'E7(0 <br />Street Address City <br />License Plate #: Li Rt ( s ic,c--,, 4) Year: ADS <br />Vehicle Vin #: Li ,( y ci 2,02,6ay'r) 1 vin 5) Make/Model: C)7kikr.i\ <br />State Decal #: 6) Color: 4e Lk )(q ,11/4 1li <br />VElfidli00161EititiVORMATO - , <br />r\l‘C, Cod' ult._)C Name: Tycvnile 04 L Cour L.r-cDC bn irk (:)(ci <br />Address of Owner: a-,--).\\ ,,.. E., c-,,,f e 0 tq''') •( Laaer-1 OA_ et, S2e <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 />offi may result in permit vocation and penalties. , 0 <br />-71711 ELM a ii,e, /et-- 0 3 . iti - 20/eC ,d7 ) <br />Signature of Vehicle Operator Date <br />COMPAISSAR*06RPLATION. <br />Business Name: Stockton's Wonderful Ice Cream <br />2626 Westlane St 10(1100 <br />Owner Name: Stockton, Caltfornia 95205 <br />(299) 469-2626 Site Address: (209) 469-2073 <br />iStreet Address City \ <br />C.-- --a — id <br />Phone: (2c ) ( ( ( .6 _26 K i (-' <br />1, the commissary owner, can and will provide the necessary facilities <br />commissary as checked below: <br />z <br />Liquid & solid waste disposal ri'L U(2toren3sil washing tssicik /Store <br />for the above mentioned vehicle at my <br />frozen food 11 Vehicle wash facilities <br />& hand washing il- Store refrigerated food <br />parking [1lt6equate electrical outlets <br />i 6.3- It-i -2_016 <br />Preparation of food 11 Hot & cold water for cleaning Toilet <br />Store dry supplies ' Provide potable water El Overnight <br />Signature of Commissary Owner/Operator Date <br />HEALTIt DEPARTMENT <br />If If the commissary/food establishment is outside San Joaquin County, <br />current health permit by signing below. Commissary/food establishment <br />County. <br />the local health jurisdiction must verify <br />is in <br />Signature of County RENS Date <br />END 16-017 <br /> <br />5r6 <br />MFPU APPLICATION <br />7/18/2008