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VERIFICATION OF VEHICLE COMMISSARY _ <br /> Please provide all information requested. An incomplete application may delay appToyal. <br /> VEHICLE:INFORMATION <br /> Vehicle Name (DBA): Sabor De Mexico <br /> Address for Vehicle: 500 7th St. Ste D Modesto CA 95354 <br /> Street Address city <br /> 1) License Plate#: 4LY4092 4) Year: 1997 <br /> 2) Vehicle Vin#: 5) Make/Model: Chevy <br /> 3) State Decal#: 6) Color: <br /> •ave, n °� "w d Cfi <br /> ;VEHICLE,O1111NE NF . 'l�I.CJ��1 ;, , 3,,..,, t., �.,���, 111 ,s <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 8r 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 /> x <br /> Signature of Ve icle Operator Date <br /> ., ' <br /> i '�'io"rs fiGxa� r � a 4'xd H r 7 t u •t ter'{ r � nab'' sni k3 <br /> COMMISSARY.INF.ORMA PION s,:< <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 /> Ox Liquid&solid waste disposal ❑x Utensil washing sink Fx—]Store frozen food ❑X Vehicle wash facilities <br /> (2 or 3 compartments) <br /> 0 Preparation of foodX❑ Hot&cold water for cleaning ❑X Toilet&hand washing Store refrigerated food <br /> X❑Store dry food/supplies Q Provide potable water ❑x Overnight parking 0 Adequate electrical outlets <br /> Signature of Commissary Owner/Operator Date <br /> 1Cu,'h� it M Js'��:iR1,'��P Sp��Y ie'��� goy Yt 1i . 7 +' �i a i• <br /> HEALTFI DEPARTMENT"��,: ,.�, , I �� .��,.,�t; ,�;,�.., �..,�'. � `.,.r� � .��. <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 /> This form will expire with our EXPIRATION <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 commissary on this date --------> DATE 17-d-19 <br />