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RECEIVED <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approia 04 2019 <br />VEHICLE INFORMATION S ENVIRONMENTAL HEAI <br />PERMIT/SERVE <br />Vehicle Name (DBA): Tacos El Gallo <br />Address for Vehicle: 1211 S. 7th St Modeso, CA 95351 <br />Street Address City <br />License Plate #: 3L21486 4) Year: 1986 <br />Vehicle Vin #: 16CHP32MXG3322413 5) Make/Model: Chev / VA <br />State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: Antonio Paez <br />Address of Owner: 2427 Sylvan Ave Modeso, CA 95355 <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 />/ <br />Signature of Vehicle Operator Date <br />COMMISSARY INFOIRMATION <br />Business Name: Cold Storage Commissary Inc. DBA: La Comisaria Modesto <br />Owner Name: Alfonso Meraz Manager <br />Site Address: 1211 S. 7th St Modeso, CA 95355 <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 />X Liquid & solid waste disposal Ix 1 Utensil washing sink X Store frozen food X Vehicle wash facilities (2 or 3 compartments) <br />15 1 Preparation of food lx 1 Hot & cold water for cleaning 1 X1 Toilet & hand washing 171 Store refrigerated food <br />X Store dry food/supplies X Provide potable water I X I Overnight parking X Adequate electrical outlets <br />------- <br />/? / 2Ce cr <br />.-------- <br />ignat—Ure 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 Stan islaus <br />County. <br />Signature of County REHS Date <br />END 16-017 <br />7/18/2008 <br />This form will expire with our <br />commissary on this date 5 of 6 <br />EXPIRATION <br />DATE 41 /7 -Lc, MFPU APPLICATION <br />TH