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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 VERIFICATION FR MOBILE FOOD FACILITIES <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 Nam e611g.y <br />V 3hicle Make ' Model: l <br />- <br /> <br />Licenso # <br /> <br />Year <br /> <br />Phone • 0. 5 -5 <br /> Ie- 1,74 _ Permitee's Name <br />Type of operation El MFF 1FFF with Lirnite( i Food Preparation <br />Address :i5: <br />tg.e• y <br /> <br />Sate !C Zip <br /> <br />COMPISSARY IIVORMATION <br />8w-r. s Narne <br />— - <br />Address ,S7.6 o t -7-1-t. 17- <br />,ity itel a dc I S te& Zip <br />Phone <br />(.; 6.'`& Commissary within Stanislaus County LP:1ES II] NO <br />AUTHORIZATION (to be completed by Commissary owner/authorized representative) <br />'Z—CA /10 /al/21/re cOf (Ct 7Le‘ has permission to use the above MFF busineas operator <br />en-- Refrigerated food storage <br />ki----Cooking food ee-Rapid cooling of food <br />El/ Dry food storage <br />Supply potable water <br />12/ Ware-washing , <br />2/ Waste grease removal <br /> <br />e-Toilet & hand-washing <br />Z"Vehicle cleaning El Electrical hook-up <br />wistewater from an MFF must be discharged to a wastmater system through a grease interceptor. <br />le California Retail Food Code requires that mobile food facilities operate from approved commissaries. Mobile food <br />,cili s are to report to the commissary at least once each operating day for cleaning and servicing operations. I agree <br />iiiimedirltely notify the Stanislaus County Oepartment of Environmental Resources if the vehicle business operator <br />sconf web the use of this commissary. <br />_ /7/ s /140&''e s <br />MFF business name <br />wood stablishment-as a commissary. The commissary can accommodate the vehicle business owner with the falonving <br />'unctions (check all that apply): <br />n---Cutting and trimming food <br />1-Washing- and cleaning food <br />Supply food product <br />1- Waste water removal <br />] Ove night parking <br />ctrimiry Operator's Name (print): <br />Dmmissary Operator's Signature: X <br />iit (print):- (7.7- .1eCe e:(C; <br /> /— <br />Date: X <br /> <br />/ /694e <br />tie a, ^ve- entioned MFF owner/opera or have answered the questions to tht -est of my knowledge, and will operate <br />it of th Dve-mentioned commissary and report to the commissary at least one each ';,rating day for cleaning 'Ind <br />rvicir q (a- ioted above). If the use of the commissary is discontinued, I will notify the St,:nislaus County Departmt;nt of <br />ivironinetital Resources to make tkiS-necessary changes. <br />=F operator's Signature: X Date: X - <br />2009 VVorking\Commissary TF\Commissary Application.doc