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.= <br />This form vein expire with our EXPIRATICoim <br />commissary on this date > DATE 3 <br />VERIFICATION OF VEHICLE COMMISSARY-- - - <br />Please provide all information requested. An incomplete application may delay- approval. <br />- <br />VEHICLE INFORMATION _,, 7.,_, - ----->r:::•." , 1 <br />Vehicle Name (DBA): El Mexicano Churros Rellenos (209) 712-9377 <br />Address for Vehicle: 17066 Jack Tone Rd. Lodi, CA 95240 <br />Street Address City <br />License Plate #: 4ND9092 4) Year: 2014 <br />Vehicle Vin #: CA1143260 5) Make/Model: SPCNS <br />State Decal #: 6) Color: oRANGE <br />VEHICLE OWNER INFORMATION <br />Name: Raul Calvario <br />Address of Owner: 17066 Jack Tone Rd. Lodi, CA 95240 <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 />discontinue., the permit holder must notify this office to make the necessary changes. Failure to notify this <br />office ma es t in pen i it revocation and penalties. <br />0/ / / <br />Signatu - of Vehicle Operator .Th Da e <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 /> washing X Liquid & solid waste disposal rx1 Utensil X Store frozen food X Vehicle wash facilities ( 2o 3 <br /> compartments) <br />1->1 Preparation of food X Hot & cold water for cleaning 151 Toilet & hand washing X Store refrigerated food <br />_ — <br />[-X- Store dry fo /supplies Provide potable water .2( Overnight parking X Adequate electrical outlets <br /> <br />„i./..144440 eA4A--,S , / • 3 ./g <br />Si ture of Commissary Owner/Operator Date <br />HEALTH 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 <br />County. <br />Signature of County RENS Date <br />END 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008