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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> �` T'�.r4� .a'e�-5.4.-.^-.`�'✓'i1�32 tbsi ��Nr� eY-s�t�c7m � --R`>�'"trf <br /> Vehicle Name (DBA): <br /> 5IS 0� ` <br /> Address for Vehicle: 'T'\\Cj 'p c�.l' ^,7�;1 S `� l V ��1 J C�GJ�•?� <br /> Street Address city <br /> 1) License Plate#: kT 5 4) Year: RD 3 <br /> 2) Vehicle Vin#: 5) Make/Model �,VA X R <br /> 3) State Decal#: 6) Color: r <br /> Name: wyae; A(_ �LYn oar Cla, '' JC- <br /> Address of Owner_ as & r !`;. . � '� All, �YC�-f� �t. q-- <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 /> offic, may result in permit vocation and penalties. <br /> 261/ <br /> Signature of Vehicle Operator Date <br /> �[�.M�11�,►�+1�►Rt�l'�11�1F�$II 'JO�i�,�- � _ _ _ - - <br /> Business Name. Stockton's Wonderful Ice Cream <br /> 2626 Westiane St#K1 100 <br /> Owner Name: Stockton,California 95205 <br /> Site Address: (2U9)4t59-2626 <br /> 209 469-2073 <br /> IStreet Address city - 1 C%K %L A/ <br /> Phone: (�cl) G{ �i' - -2,( �6I 1S_R <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> 0 Liquid&solid waste disposal Utensil washing sink <br /> (2 or 3 compartments) Store frozen food ErVehide wash facilities <br /> ❑Preparation of food Hot&cold water for cleaning E Toilet&hand washing []-Store refrigerated food <br /> ❑Store dry ood/supplies Q Provide potable water 0-6vemight parking O-Adequate electrical outlets <br /> Signature of Commissary Owner/Operator Date <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 />