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This form will expire with our EXPI94TION <br /> commissary on this date --------> I DATE0070 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): Tacos EI Paisano <br /> Address for Vehicle: 312 Sundance Way, Modesto, CA 95351 <br /> Street Address City <br /> 1) License Plate#: 8U91916 4) Year: 1974 <br /> 2) Vehicle Vin #: CPY354V318864 5) Make/Model: CHEVY <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: Robert Leon <br /> Address of Owner: 312 Sundance Way. Modesto, CA 95351 <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 res It in permit revocation and penalties. <br /> Vignaft ure of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: Cold Storage Commissary Inc. DBA: La Comisaria Modesto <br /> Owner Name: Arturo Vaca: Manager <br /> Site Address: 1211 S. 7th Street, 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 /> ❑X Liquid&solid waste disposal X❑ Utensil washing sink 1K Store frozen food ❑X Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑X Preparation of food X❑ Hot&cold water for cleaning ❑X Toilet&hand washingX❑ Store refrigerated food <br /> ❑X Store dry food/supplies ❑ Provide potable water ❑ Overnight parking ❑Adequate electrical outlets <br /> nature 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 <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />