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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INF0RMATI0N:',, ,_ ., Vehicle Name (DBA): i l (' R L4 Address for Vehicle: S C OGKTD/V 9sL Street Address city 1) License Plate #: 701570 C I 4) Year: I q$q 2) Vehicle Vin#: 16)(F6 2-SK7 7-rz7194lake/Model: 5jAfC V,4y 3) State Decal#: 6) Color: VEHICLE OWNER INFORMATION Name: % h --- Address of Owner: 6 ( �� vie Tb CK 7-0A1 Cog qSj-to Street Add ss city The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CaICOde sections 114295 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office ma result in permit revocation and penalties. / j - Z- �%l 2- Signature Si nature of Vehicle O erator Date Business Name: Owner Name: ^ Site Address: Street Address C ty Phone: (')-.g) G\\.kF-- l'lv I, the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: F-1Liquid&solid waste disposallo'EJ Utensil washing sink 1-1 Store frozen food �❑ Vehicle wash facilities (2 or 0 compartments) �4 ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing -�& Store refrigerated food ❑ store dry food/supplies ❑ Provide potable water Overnight parking �Adequate electrical outlets PICK'N GO ICE CREAM x3588 E.CARPENTER RD. Signature of Commiss Owner/O erator Date ON,CA 95215 i If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County RE HS Date EHD to-017 5 of 8 MFPU APPLICATION 7/18/2008