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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> i i <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): Lupitas Cocktail & Food#2 AR 0 9 2019 <br /> Address for Vehicle:730 S. California St. Stockton <br /> Street Address f11Ef City <br /> DI-AIARThIEN'r <br /> 1) License Plate#: 4HU9171 4) Year: 2015 <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal #: N/A 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: Jose Martin <br /> Address of Owner:2844 S Monroe Ave Stockton <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 /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: Cold Storage Commissary Inc. DBA: La Comisaria Modesto <br /> Owner Name: Arturo Vaca: Manager <br /> Site Address: 1211 S. 7th St. Modeso, 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 /> x0 Liquid &solid waste disposal 0 Utensil washing sink 0 Store frozen food ❑X Vehicle wash facilities <br /> (2 or 3 compartments) <br /> X� Preparation of food X Hot&cold water for cleaning ❑X Toilet&hand washing ❑x Store refrigerated food <br /> F Store dry food/supplies [R] Provide potable water 0 Overnight parking ❑X Adequate electrical outlets <br /> <t��� 0-+/0 LIN <br /> Si ature 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 Stanislaus <br /> County. <br /> Signature of County REHS Date <br /> FcTom—his form will expire with our EXPIRATION <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 missary on this date --------> DATE 04I0VL0 <br />