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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An incomplete application may delay approval. <br /> f"r.�'' Ss�-`.: r!""':;Y,?5'E`}V.t =r: - 'kas'r.'".s .: .:3snPR� F' -✓a y..J.*' �cic�':Rn y-3s ,2:=,•'x.--'-a=t <br /> 7- �'SP'�S •'-,,,ater6 f <br /> P1 la r2r <br /> Vehicle Name(DBA): <br /> Address for Vehicle:.2 a a ,;OVA <br /> Street Adctress City. <br /> 1) License Plate#: E� C Z2 L�.-I _ 4) Year: 2_000 <br /> 2) Vehicle Vin#: IF/ A E I q 2X h 3$5� lake/Model: <br /> 3) State Decal-#: 6) Color: <br /> -p—SK <br /> Name: A4 N P,-r - - <br /> Address of Owner: <br /> Street Address City <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 114295 & 't14297): if the use of the commissary is <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office may result in pefmit revocation and penalties. <br /> Signature of Vehicle O erator Date <br /> IN <br /> ;c....fs :Y+s Y�3:�Yjm ''ra•'iL.ixt'1.•w. .x•"-�, a-r"rd{.� _..' 4�� ... � t i tet. � ?t.�r �i � .i5- '7 .+•' :�'v2' `tGt2-�-mss+'$-.��� <br /> �N1I�11,SSf' N� 8�11 ►TaC ' J �r: � `_= ; - x 3:t: <br /> Business Name: PN" C C C <br /> Owner Name: S°,. e7/° ' <br /> Site Address: 3S - cA 4 P Cay/ TC (V QA rkr <br /> Street Address city <br /> Phone:,(") Of <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 <br /> Utensil washing sink "'2 Store frozen food(2 or 3 compartments) 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. Overnight parking Adequate electrical outlets <br /> PICK'N GO ICE CREAM .:. <br /> C ls588 E..:CAR•PENT.ER:RD. <br /> Signature of Com miss Owner/Op'erator Date• ST'OC' s Oi ,.CA. 95215 <br /> Ing- "" n r* i .N• ��-'.� f-' <br /> � <br /> i^�4--.-a..-�...z�+„'r+ �..a,, z._...,.ems .,at.z-__ ��teo-'cfi..�# ..�:="3»".!"�_:._F'x.. ..'F:._c. _ ,r.T1a.�.er;F.-,.< ti�`.�s:r.+:t,.__•S".�+�`'�.+_ <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 MFPU APPLICATION <br /> 7/16/2008 <br />