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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may deiay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): E�0.}e ,Spa-}- <br /> Address for Vehicle: ( 0 SOX 534 Ca, gS30zl <br /> Street Address City <br /> 1) License Plate#: Li HG 222—4 4) Year: 200 <br /> 2) Vehicle Vin #: 5005922o-4 5) Make/Model: 'FAgWE <br /> 3) State Decal #: COY 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: 1_v�S (�v rv � -4\vc,�,Z <br /> Address of Owner: P-C) 0 wg <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 iGO� it revocation and penalties. <br /> I�- U--� ' ?-oI 5 <br /> Signature of Vehicle Opeator 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 /> Liquid&solid waste disposal �Utensil washing sink(2 or 3 compartments) Store frozen food ZI Vehicle wash facilities <br /> Preparation of food Hot&cold water for cleaning Toilet&hand washing ® Store refrigerated food <br /> Store dry food/supplies r' Provid potable water Overnight parking ZI Adequate electrical outlets <br /> /� v I' L ' 8 <br /> Si nature of Commissary Owner/O erator Date <br /> EALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must veri y <br /> current health permit by signing below. Commissary/food establishment is in IA-Gr Cyv� y <br /> County. <br /> i <br /> i <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />