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VERIFICATION OF VEHICLE COMMISSARY."CEIVED <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): Lupitas Cocktails <br />Address for Vehicle: 1211 S. 7th St. <br />Street Address <br />JAN 1 4 2.1321 <br />Modesto <br />1RON:111%.\ FAL HU ALTII <br />DITARTN ENT <br />City <br />License Plate #: 4CS3586 4) Year: <br />Vehicle Vin #: S640881525 5) Make/Model: <br />State Decal #: N/A 6) Color: <br /> <br />1976 <br /> <br />APCHE CMP <br /> <br />VEHICLE OWNER INFORMATION <br /> <br />Name: Jose Martin <br /> <br />Address of Owner: 2844 S Monroe Ave <br /> <br />Stockton <br /> <br />Street Address <br /> <br />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 office may result in permit revocation and penalties. <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: Cold Storage Commissary Inc. DBA: La Comisaria Modesto <br />Owner Name: Laura Lopez Office Manager <br />Site Address: 1211 S. 7th St. <br /> <br />Modeso, CA 95351 <br /> <br />Street Address <br /> <br />Phone: ( 209) 338-3663 <br /> <br />City <br /> <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: <br />Liquid & solid waste disposal IX I <br />(2 or 3 compartments) <br />Utensil washing sink Ix! Store frozen food Ix I Vehicle wash facilities <br />Hot & cold water for cleaning IXI Toilet & hand washing I XI Store refrigerated food <br />X ore crpplies FCI Provide potable water Ix! Overnight parking 15.(1 Adequate electrical outlets '-' <br />61- 13 • "2-02-4_ <br />Signature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />Ix1 <br />Ix! Preparation of food <br />IX I <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 Stanislaus County. <br />Signature of County RENS Date <br />EHD 16-017 <br />7 /18/2008 <br />iThis form will expire with our EXPIRATION commissary on this date 5 of 6 <br />DATE c)I '13 •74)--' MFPU APPLICATION