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i ;1Crr4 <br /> Environmental Management <br /> Department _ 4" <br /> Divisions <br /> Val F. &ebal, Director i Envlronmental Health <br /> Environmental Coeipliance <br /> 9irfoaH+!'. <br /> ---------S202UnTY of Sacramento <br /> COMMISSARY or MSU VERIFICATION <br /> MOBILE FOOD FACILITY(MFF)/MULTI EVENT VENDORS(ME )/CATERER FA# <br /> MFFIMEWCATERER BUSINESS INFORMATION: <br /> TYPO orFaeiury: O ME•V ❑4FT-Cat.A 0%1FF-Cat.B <br /> F'nud re at commissary MPF-Gat•C EI/MFF,Ut.D ❑CATFRF.R <br /> MFF/Mr-V/Caterer Business Name: <br /> License Plate Number(if applicable): i <br /> Owner Name; <br /> Owner Mailing Address• <br /> Phone Number-(Home) � t �(;t~• ;�(r•-fin r ---�—'--- <br /> 5�rcily tt: Y�c tr1� 'Lip Code: <br /> _�.�(.( ( - '� I _ <br /> WE'S nNl,l __ (Mobile) �-Jc ? U !y--291 <br /> How will the refrigeration be powered ou the mobile writ when it is operating away from sar the commissar)"?� r 5 r�¢.gatualex,mvcrter,etc,.) <br /> 4 thertretrNoner �(Fl F 9�'F% n[n <br /> S rcr Cft=will Operrrte unt of the below me I oned co[nnrissary anr�lu the - <br /> conunisaary a1 least once elect,operating day for cleaning and servicing <br /> ve/dcle(if applicable)n[the approved commissary or another approvelocation.!/f l�rVu(¢f the conunisfrt[y is lli l vill star,t tl <br /> will notify life Entrrarmrerdul Health Division n[(9/6)975-8440 to nrnkr der nee cssrrry cW a rt. <br /> Signature of MFF/MEV/Caterer Owner <br /> Dash <br /> COMMISSARY INFORMATION: <br /> Type of Facility <br /> EJ commissary ❑MSU <br /> Commissary Business Name: dRestaurant El Market <br /> 1 F1 Other <br /> �G� <br /> Commissary Owner's Name r i -- <br /> Commissary <br /> Commissary Address:-�����v"�l.l,S_ �.���•Ci < � _----- -- <br /> Ph ne Number:(Business) city Zip C e. 1 � <br /> -- (Mobde) �• ) { <br /> l' Preparatiop or packaging or rood f ) <br /> / tom► 1'utabte%vaterauppt) IY pvcrnightparkipg <br /> IJi Electrical hooi.•up / <br /> /// I �1 �'arnrashipg <br /> ( I <br /> Toilet&banAw:uhiak ,1j„ Rerrigeratew rrozen rood storage <br /> (v�\Vaste tattW se+rat;c disposal facilitfrs I"J"ry rood storage / <br /> VJjSopptfrs storage <br /> I I 11'rite gyrase removal I �uppty rood produce <br /> p mfued jsarr[hynrr, can and tail/proridr[ler nee rrsrrrt facilities as checked for the above-me ntinrred MFF%M6;%Caterer at <br /> my permitted jrrci/ihr: �"'� <br /> S• nature of Commissary Owner <br /> Date <br /> NOTE; The signature of Commissary Uwner alust be a nwloriginal rvitlrill 3U cloys of rrpp/t•irrg fire perhtiG A'U COYIE.S <br /> LO—TE,:Use of an unapproved facility for any orabut a purposes can Iced to revocation or your pet-mit to operate. <br /> Commissary Apprpval• 1 Pending <br /> O Approval 3 Dcsappi ved <br /> Verified by <br /> so <br /> Date Rean <br /> oar +.aarn;••wasaars r NKF - —__ <br /> ry vek. cwt•a rvR V,iF nfx+ i u a ave <br /> 10590 Armstrong Ave.Suite B • Mather,CA 95655 • phone(916)875-8440 • fax(916))875-8!j13 • vnvw emd.saccounty.net <br /> I <br /> I <br />