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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATIQA <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#: 8V36552 4) Year: 1996 <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> xnrnux �,.rs,,n s��, rrK 'k•�^�. <br /> V, <br /> EH r <br /> E 01NI�EFt1". FOR,MA' ,Lf J .. �a��N .�. �,..w�., ��� # ��,.,� :�.., 40,10141 Q k�, <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 & 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 /> �<, / Z 2 �- 2,�,d,? <br /> Signature of\Nhicle Operator Date <br /> ��C`'O'MMIS`S"�AR�Y,INFORMA"�'T�1�.�4. � ,• . .. . <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 /> XI Liquid&solid waste disposal ❑x Utensil washing sink 0 Store frozen food ❑X Vehicle wash facilities <br /> (2 or 3 compartments) <br /> x0 Preparation of food XO Hot&cold water for cleaning ❑X Toilet&hand washing QX Store refrigerated food <br /> Q Store dry food/suppliesx❑ Provide potable water 21 Overnight parking �X Adequate electrical outlets <br /> Si nature of Commissary Owner/Operator Date <br /> e�ri { � ,�,i�y _ i�4 r�in� t � ,'}rt S:i3�id3 �i.iT �5 A'M�i.,r tT� �lrl�3 <br /> HEALTH;DEPARTMENT ;. . , GF) !:,rl.., ::. ,,e irF . m.#,. :.. <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 This form will expire with our 5of6 EXPIRATION MFPU APPLICATION <br /> 7/18/2008 commissary on this date --------> DATE 12-2.3--Iq <br />