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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): Tacos El Coyote y Su Tropa Loca <br />Address for Vehicle: 178 Collin Ave #2 Tracy, CA 95376 <br />License <br />Vehicle <br />State <br />Street Address City <br />Plate #: 1JD1069 4) Year: 1996 <br />Vin #: CA712856 5) Make/Model: SPCN <br />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 />The mobile f. • <br />operatins • ay fs <br />discon • s : s , t <br />offic- ay:- I ...... IL <br />Street Address City <br />cility shall operate out of a commissary and shall report to the commissary at least once each <br />c -aning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />p- mit holder must notify this office to make the necessary changes. Failure to notify this <br />p rmit revocation and penalties. <br />07/01/2019 <br />SignMILof r-07- Operator Date <br />COMMISSA 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 />13-1 X Utensil washing sink ( Liquid & solid waste disposal lx] Store frozen food X Vehicle wash facilities <br />(2 or 3 compartments) <br />I-Ti Preparation of food Ix I Hot & cold water for cleaning X Toilet & hand washing ril Store refrigerated food <br />>17 Store dryf7d/supplies [71 provide potable water X Overnight parking Fl Adequate electrical outlets <br />,---- 0. I , 07/01/2019 <br />Signakire of Commissa Owner/O•erator Date <br />1711,,EALTH DEPARTMENT <br />If the commissary/food <br />current health permit <br />County. <br />establishment is outside San Joaquin County, the local health jurisdiction must verify <br />by signing below. Commissary/food establishment is in Stanislaus <br />Signature of County RENS Date <br />EHD 16-017 <br />7/18/2008 <br />This form will expire with our <br />commissary on this date 5 of 6 <br />EXPIRATION <br />DATE ,.1.1.1x11•1) MFPU APPLICATION