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Environmental Management q°'a °q4 Divisions <br /> Department ; o Environmental Health . <br /> Val F. Siebal, Director ¢ $ Environmental Compliance <br /> Qq <br /> g40bn , <br /> County of Sacramento <br /> COMMISSARY or MSU VERIFICATION FA# <br /> MOBILE FOOD FACILITY(MIFF)/MULTI EVENT VENDORS MV)/CATERER PR# <br /> MFF/MEV/CATERER BUSINESS INFORMATION: 1 <br /> Type of Facility: ❑MEV ❑MFF-Cat.A ❑MFF-Cat.B ❑MFF-Cat.C LI MFF-Cat.D ❑CATERER <br /> (Food area at commissary) <br /> MFF/MEV/Caterer Business Name: W 41 t�j en, C 1 1/ i� <br /> License Plate Number(if applicable):f ?)q rf/�j5(p 1 <br /> Owner Name: �(,1 H'�.11-fire" JI�VI`Ile f 1E <br /> Owner Mailing Address: VU gox 111 b City: CdgfLwtlC/4tR Zip Code: � oq <br /> Phone Number:(Home) (11 (Mobile) <br /> MFF'S ONLY: ' <br /> How will the refrigeration be powered on the mobile unit when it is operating away from the commissary? (i.e.generator,inverter,etc,.) <br /> Cq thlll&01162 <br /> I,the above-mendoned MFF/MEV/Caterer Owner will Operate Out Of the below mentioned commissary and Wattle the <br /> commissary at least once each operating day for cleaning and servicing(As noted below)(Calcode Sea 114297). 1 win store the <br /> vehicle(if applicable)at the approved commissary or another approved location. if the use of the commissary is discontinued,I <br /> will notify the Environmental Health Divislon of(916) 440 to make the necessary changes <br /> �Ih <br /> Signatur F/MEV/Caterer Owner Date <br /> COMMISSARY INFORMATION: <br /> Type of Facility: `Commissary ❑ MSU El Restaurant ❑ Market El Other <br /> Commissary Business Name:: e- e,—t T ted el r <br /> Commissary Owner's Name: l "c- r- ' <br /> Commissary Address: 1 1 CC) Lj( t 4 City: r,Lrr _Zip Code: ?t� i t <br /> Phone Number:(Business) 6/40 '411 r22 Y:) (Mobile) G,? (a q X-0rr rr <br /> J/`Prepaatiou or padugiag of food Li-Potable water supply 14 Overnight parking <br /> of Electrical hook-up t<Wsrewsshing .e'1 Refrigerated/frozen food storage <br /> -J Toilet&bandwasbing 7 I ory food storage YfSupplies storage <br /> lie'waste tsaW sewage disposal lacilides waste grease removal I I Supply food product <br /> I,the COnunlssary Owner can and wiU provide a necessary facilities as checkedfor the above men/doped MFF/AfEV/Caterer at. <br /> my perms ae Ll �1 1 <br /> tgnature of Co Owner r Date <br /> NOTE:The signature of Commissary Owner must be a wet/original within 30 days of applyingforpemlit NO COPIES <br /> NOTE:Use of an unapproved facility for any of above purposes can lead to revocation of your permit to operate. <br /> Commissary Approval: o Pending ❑ Approved ❑ Disapproved <br /> Verified by: <br /> Date: Reason: <br /> W'pY'ENa0aM1L4a rRO1ECTBN6r,yyTW MONOaarpLeaaMa/•'IArT Foa,sawwmurs <br /> worto oocsoonuna.cwuaw+rveununoa,,,s un« <br /> 10590 Armstrong Ave.Suite B • Mather,CA 95655 • phone(916)8754440 ' fax(916)875.8513 - www.emd.saccounty.net <br />