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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 (DBA): .E. \o€ <br />Address for Vehicle:(1..0 Beri< S34 ‘1\ics4\c/ , co, c'‘S38 <br />Street Address City <br />License Plate #: t-i \AG 2-22 - 4) Year: 2_00-4 <br />Vehicle Vin #: 500592qcY4 5) Make/Model: <br />State State Decal #: CA 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: L_\)\ 5 pw-ry,cAy\do 4\vo,vez <br />Address of Owner: P. 0 0.) 5-31-i Ni\le4-\:itl I C°%. 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 ermit revocation and penalties. <br />Signature of Vehicle OpAtor Date <br />COMMISSARY INFORMATION <br />Business Name: Cold Storage Commissary Inc. DBA: La Comisaria Modesto <br />Owner Name: Arturo Vaca: Manager <br />Site Address: 500 7th St. Ste. 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 />WE Liquid & solid waste disposal Utensil washing sink IA Store frozen food igi Vehicle wash facilities (2 or 3 compartments) <br />t/Preparation of food Z,Hot & cold water for cleaning 2 Toilet & hand washing Store refrigerated food <br />RStore dry f ad/supplies Provid potable water g Overnight parking ix-i Adequate electrical outlets <br />fr/ , t i • 1- • 13 <br />SiTature of Commissary Owner/Operator Date <br />ITEALTH DEPARTMENT <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 7---S irr--r\ \ S IAA: -3 Cc_AA-vi-y <br />County. <br />Signature o County RENS Date <br />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008