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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 \0 Ae Spo# 42 1-4 IA - <br />Address Address for Vehicle: i?-c. BD< S34 wics-A-Nelf , co, c‘s3eq <br />Street Address City <br />License Plate #: Li 1A6 222 g- 4) Year: 2-00.- <br />Vehicle Vin #: 50059 2q0-4 5) Make/Model: <br />State State Decal #: CA 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: LvIs Av-iy,e ,eva0 -4\vcmez <br />Address of Owner: P. o f,c3-,c s--31 Wes-V\ey cc,. cls-3,2)4 <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 ermit revocation and penalties. <br />a-01 e - II- C)-- & <br />Signature of Vehicle Opkor 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 />il n W w "t siic/ Liquid & solid waste disposal Uteashing snk X Store frozen food Fl Vehicle wash facilities (2 or 3 compartments) <br />VPreparation of food ZHot & cold water for cleaning 2 Toilet & hand washing la Store refrigerated food <br />.1, <br /> <br />KStore dry f.od/supplies OW Provid potable water tgi Overnight parking N Adequate electrical outlets <br />I <br />INV. dr , it• 4-• iS <br />er ure of Commissary Owner/Operator Date <br />EALTH 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 <br />County. <br />Signature of County REHS Date <br />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008