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Ran/ <br />'?1 <br />—.IL <br />I I 1. <br />_it_ <br />State !Ohl Zip <br /> <br />0 IL <br /> <br />r! . <br />Date:- X if <br />Ikrc ES 0 NO <br />hor operator's Si nature; X <br />Nov. 21: 2017 10:45AM Stan County Env <br />110. <br />A-Hn' <br />Resources t i,.43136,/ <br />DEPARTMENT OF ENVIRONMENTAI, RESOURCES. <br />3800 Cornucopia Way, Sullo C, Modesto, CA 96368-0492 <br />Phone; 209.525,6700 u Fax 209.625.6774 <br />www,atancounly.corn <br />elwrIps is to. ho 11.1 <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 al 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 •1 <br />Business Address <br />City <br />Phone AlklIFY:";%11.0[1]-1.-L111A!! County <br />Inspector's Name iL" "4 'IN' • 11.V.' <br />:''i_.."-ire: 'rcl.--ert..t1 (4-11 .<t-1:51f44-(j...I . Job Title !,-.*., Phone • i <br />Inspector's Signature: X.,_ 1,1 9) <br />Will the mobile food facility be stored at the Commissary overnight? <br />Does the mobile food facility possess a generator or inverter to supply power to the cold holding unit c_litring transit? <br />fri YES Eli No <br />Has the inverter received approval from the California Department of Housing and Community Development? <br />YES • LI 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 of the commissary is discontinued, I will notify, the Stanislaus County Department of <br />Environmental Resources to make the necessary c <br />Date,: x 2.1— 2.ct I 3 <br />iRecer ved T rriekNo v. 21: '-2017010: 39ANNo. 2611doc