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VERIFICA jION OF VEHICLE COAISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): E... Lok s pol_ <br />Address for Vehicle: p.O iox s39 kNies -k Iej , cc‘ C:15 3 € <br />Street Address City <br />License Plate #: Li 3- 0 R-59 4) Year: <br />Vehicle Vin #: LC,AA3()T Pa I Liss3c,2, 5) Make/Model: Low 1-k) u -riL, <br />State Decal #: cA. 6) Color: GREY <br />VEHICLE OWNER INFORMATION <br />Name: k 5 Poe max-vAo /6,s Wcorrl <br />Address of Owner: (),() Box G39 We-SAlkeY ) cc \ °1E38 <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 />office may result in permit revocation and penalties. <br />02411. 2,011 <br />Signature of Vehicle Operator Date . , <br />COMMISSARY INFORMATION ' .W-4 . " ' 4, -'11't' . 4. <br />Business Name: Cold Storage Commissary Inc: La Comisaria Modesto <br />Owner Name: Arturo Vaca: Manager <br />Site Address: 500 7th St. D Modesto, Ca 95354 <br />Street Address City <br />Phone: ( 209) 338-3663 <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 />washingil i 2\ Liquid & solid waste disposal )4' Utens snk zi Store frozen food 21 Vehicle wash facilities (2 or 3 compartments) <br />rx Preparation of food I-A Hot & cold water for cleaning NToilet & hand washing N. Store refrigerated food <br />I-A Store dry food/supplies Provide potable water IX1 Overnight parking gj Adequate electrical outlets <br />0 <br />.41/1 -4/4-417' .a...doilli Z. - / -N. • 2.c.,1 a) <br />Sure of Cornmissaryilw er/Oserator Date <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local health jur*liction must yerify <br />current health permit by signing below. Commissary/food establishment is in 5-\=.4-•ts laws cov.ev4-7 <br />County5 <br />-201`)* <br />Signature of CountiTZEHS Date <br />END 16-017 <br /> <br />5 of 6 <br /> <br />MFPU APPLICATION <br />7/18/2008