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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 (DBL,( , c , <br /> Address for Vehicle: C?"6 L4-.,4t 91C x'1100 <br /> Street Address cit, <br /> 1) License Plate#: 4) Year: 604, <br /> 2) Vehicle Vin#: 5) Make/Model: C ff�bLE 4 <br /> 3) State Decal#: tar 4 So?66230 6) Color. t:t91t fre <br /> VEHICLE OWNER INFORMATION <br /> Name: e� e,_ <br /> Address of Owner: 3141/ 26-- <br /> Street Address City <br /> The mobile food acHity shall operate out of a commissary and shall repor t i0 uie commissary at`east 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 /> o ay r in ermit revocation and penalties. <br /> Signature of Vehicle O erator Date <br /> COMMISSARY INFORMATION <br /> Owner Name: [�{LS1nI ND— o V- f6U.dVIIL7tk <br /> Site Address: � �f�,�,F Flo c� cK1�� 4 � S <br /> t�G G,. <br /> Street' <br /> City <br /> Phone: ( c�. L156.2/6 4 <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 /> `quid&solid waste disposal 0�sil washing sink tore frozen food Vehicle wash facilities <br /> 12 or ompartments) <br /> ff_Preparation of food Hot&cold water for cleaning oilet&hand washing re refrigerated food <br /> ©S re <br /> foo /s lies Provide potable water ELOve fight parking ©equate electrical outlets" <br /> Ckton's Wonderful Ice Cream <br /> 2 6 N.West Ln Ste#K1100 Ll /a a0 <br /> Si natur of Commissa Date <br /> HEALTH:DE0,ARTME49f 469 2073 <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 /> EH0.16-017 5 of 6 MFPU APPLICATION <br /> nte/2oos <br />