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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLEINFORMATION <br /> Vehicle Name (DBA): Tacos EI Coyote y Su Tropa Loca <br /> Address for Vehicle: 178 Collin Ave#2 Tracy, CA 95376 <br /> Street Address City <br /> 1) License Plate#: 1JD1069 4) Year: 1996 <br /> 2) Vehicle Vin #: CA712856 5) Make/Model: SPCN <br /> 3) State Decal#: N/A 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name:Gabriel Alviter <br /> Address of Owner: 178 Collin Ave#2 Tracy, CA 95376 <br /> Street Address City <br /> The mobile f ciIity shall operate out of a commissary and shall report to the commissary at least once each <br /> operatin ay f �c aning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discon ' , t I p mit holder must notify this office to make the necessary changes. Failure to notify this <br /> offic ay re I p rmit revocation and penalties. <br /> 07/01/2019 <br /> Sin Ior of Operator Date <br /> COMMS-AW 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 95351 <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 <br /> (2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> x❑ Preparation of food x❑ Hot&cold water for cleaning ❑X Toilet&hand washing Store refrigerated food <br /> 0 Store dryfopd/supplies Provide potable water 0 Overnight parking ❑X Adequate electrical outlets <br /> il"-� , 07/01/2019 <br /> Znature of Commissa Owner/Operator Date <br /> LTH 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 Stanislaus <br /> Coun <br /> -01 - wFA <br /> Signature of County REHS Date <br /> This form will expire with our EXPIRATION <br /> EHD 16-017 5 of 6 9 MFPU APPLICATION <br /> 7/18/2008 commissary on this date --------> DATE <br />