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kix,‘ 0 A C- e a r Permitee's Name <br />I 5 ( 5- tct Address A- NI e <br />Business Name The Market Modesto <br />Address 5 0 0 7th St. <br />City State c A Zip 9 5 3 5 4 Modesto <br />Phone 2 0 9-3 3 8-3 6 6 0 Commissary within Stanislaus County IX YES 17] NO <br />MFF business operator <br />food establishment as a commissary. <br />functions (check all that apply): <br />MFF business name <br />The commissary can accommodate the vehicle business owner with the following <br />c <br />Phone <br />License # 1 0-6 33 11 <br />Year 2-c 0 5- <br />Date: X <br />EXPIRATION <br />DATE 9, D z I <br />COMMISSARY VERIFICATION FOR MOBILE FOOD FACILITIES <br />DEPARTMENT OF ENVIRONMENTAL RESOURCES <br />3800 Cornucopia Way, Suite C, Modesto, CA 95358-9492 <br />Phone: 209.525.6700 • Fax: 209.525.6774 <br />www.stancounty.com <br />Please make sure the writing is as clear as possible. (An illegible application will result in a delay or denial of a permit.) <br />MOBILE FOOD FACILITY INFORMATION <br />Business Name 1 0_, 63 6 <br />Vehicle Make ir (er Model: r <br />Type of operation al MFF MFF with Limited Food Preparation <br />State C A Zip q 5 3 2-o <br />COMMISSARY INFORMATION <br />AUTHORIZATION (to be completed by Commissary owner/authorized representative) <br /> of has permission to use the above <br />El Cutting and trimming food <br />IXI Washing and cleaning food <br />Ex Supply food product <br />[X] Waste water removal <br />E Overnight parking <br />NI Cooking food <br />Xl Refrigerated food storage <br />Supply potable water <br />Waste grease removal <br />Electrical hook-up <br />[k Rapid cooling of food <br />Dry food storage <br />ZI Ware-washing <br />Xl Toilet & hand-washing <br />k Vehicle cleaning <br />* Wastewater from an MFF must be discharged to a wastewater system through a grease interceptor. <br />The California Retail Food Code requires that mobile food facilities operate from approved commissaries. Mobile food <br />facilities are to report to the commissary at least once each oper triaiiay for cleaning and servicing operations. I agree <br />to immediately notify the Stanislaus County Depa ment of viro dental Resources if the vehicle business operator <br />discontinues the use of this commissary. <br />Commissary Operator's Name (print): <br />Commissary Operator's Signature: X <br />I, the above-mentioned MFF owner/operator have answered the questions to the best of my knowledge, and will operate <br />out of the above-mentioned commissary and report to the commissary at least once each operating day for cleaning and <br />servicing (as noted above). If the use of the commissary is discontinued, I will notify the Stanislaus County Department of <br />Environmental Resources to make the necessary cha9ges. <br />City <br />MFF operator's Signature: <br />H:12009 Working\Commissary TF\Commissary Application.doc <br />Title (print): Manag i <br />Date: X 41 00 2102AD