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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): ,ou y 1 ow i iciotis Tu i.. , <br />Address for Vehicle: 2021p N, we5-1- uot4i.Q. tc\ 1 o 0 ) -1--Daa-uNn cfi cr5z 0 Z <br />License <br />Vehicle <br />State <br />Street Address City <br />Milted ) Plate #: In prixess ( 1 1 4y Year: 0 / 8 <br />Vin #: W-1\16,1 6G-f (0j1c p0(1% 5) Make/Model: F04:6 77.44,44,S ( 1 <br />Decal #: ( ir 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: 5 R Talyvuo sayi cik_e 2._ <br />Address of Owner: "ZIO\k-k 5 0(21!D Irvedic 5 -. -1-tx-11-431/1 , CA q szo 0 <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 />off e ay result i 0 poi it revocation and penalties. <br />1 ( ( ( ( CC <br />Signa re of Vehi , e • • -1-ator Date <br />' ISSARY FORMATION <br />Stockton's Wonderful Ice Crearr Business Name:Sicx jari)Yl_S WOVIC.044 P k 'TC`e .Cf ea_vvv 2626 Westlane St #K1100 <br />Owner Name: \) .e .e jri (A Cir\conaujef Stockton, California 95205 <br />(209)469-2626 <br />Site Address: a6 a(f, N. West i _c„,,Q_, \CA CA) 3-t0 /9- CtS•zo5 <br />Street Address City / <br />Phone:( Lfto CI( — acc7 c9-(z7 <br />I, the commissary <br />commissary as <br /> Liquid & solid <br /> Preparation <br />Store dry food/sue <br />owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />checked below: <br />Ut waste disposal ensil washing sink [CirCre frozen food ehicle wash facilities <br />(2 or 3 compartments) <br /> Hot & cold water for cleaning r>15‘ hand washing St refrigerated food of food or <br />'. les P ovide potable water [rnight parking[equate electrical outlets <br />Signature of ommtssary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If the commissary/food <br />current health <br />County. <br />establishment is outside San Joaquin County, the local health jurisdiction must verify <br />permit by signing below. Commissary/food establishment is in <br />Signature of County REHS Date <br />EHD 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008