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C cA <br />q County <br />Inspector's Name V I d ot ? e41c17-0\ <br />City <br />Phone <br />State c_ A- Zip4 c3 2c) <br />S ft <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 />COMMISSARY AUTHORIZATION <br />FOR COMMISSARIES LOCATED OUTSIDE OF STANISLAUS COUNTY <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 />IMPORTANT: For any mobile food facilities operating from a commissary that is located outside of this county, the <br />operator must complete this form. <br />The mobile food facility must possess the capability of holding potentially hazardous foods at the required <br />temperature range during transportation. Using an ice chest is not an approved method to hold potentially <br />hazardous foods (except ice cream and whole fish) according to California Retail Food Code Section §113885. <br />The applicant must attach a current Health Permit of the commissary with this sheet. <br />The following must be completed, and the shaded area must be completed by the local Environmental Health inspection <br />agency for commissaries located outside Stanislaus County: <br />Business Name L a C a co -A a u <br />A e <br /> <br />Business Address ( s S j f vj A <br /> <br />Phone Job Title <br />Inspector's Signature: X Date: X <br />Will the mobile food facility be stored at the commissary overnight? <br /> YES E NO <br />Does the mobile food facility possess a generator or inverter to supply power to the cold holding unit during transit? <br /> <br />X] YES LINO <br />Has the inverter received approval from the California Department of Housing and Community Development? <br /> <br />/AC YES [11 NO <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 pf the commissary is discontinued, I will notify the Stanislaus County Department of <br />Environmental Resources to maeØ recessary ch ges. <br />MFF operator's Signature: X Date: X <br />H:\2009 Working\Commissary TRCommissary Application.doc