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VERIFICATION OF VEHICLE COMMISSAki(C) <br />\\\ Please provide all information requested. An incomplete application may delay`approval. <br />3' --•:.:‘' -,:,`." I VEHICLE INFORMATION <br />Vehicle Name (DBA): Sabor De Mexico .,,\).. v-,N , <br />, - .„-.. \I <br />Address for Vehicle: 500 7th St. Ste D Modesto CA 953'54 <br />Street Address City <br />License Plate #: 4LY4092 4) Year: 1997 <br />_ <br />Vehicle Vin #: 5) Make/Model: Chevy <br />State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: Humberto Ramirez <br />Address of Owner: 202 W. Clover Rd Tracy CA 95376 <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 />Signature of VehicIZT;rator 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 />inkhin washing s X Liquid & solid waste disposal X Utensil X Store frozen food X Vehicle wash facilities (2 or 3 compartments) <br />X Preparation of food I X I Hot & cold water for cleaning X Toilet & hand washing X Store refrigerated food <br />)71 Store dry f od/supplies X provide potable water Pi: Overnight parking X Adequate electrical outlets <br />if q. /8 <br />S •ry-ture of Commissary Owner/Operator Date <br />HEALTH 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 cf4,4 it c (4 ( ) <br />County. <br />C , <br />, I 11 ( I (, <br />Signature of Coun y REHS Date ' <br />-1his will expire with our <br />comm—ary on this date DATEPr <br />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008