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SJanf <br /> + �I DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> 3800 Comucopla Way,aulta C.Modesto,CA 05359-0402 <br /> Phonal 200.525.0700•Fax 209.525 9774 <br /> J wrnv.araraourdy.com <br /> COMMISSARY VERIFICATION FOR MOBILE FOOD FACILITIES <br /> riease meke surethe 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 9011DIA]fn ii�'If�,IfT,)I�'Ih�I®❑❑❑O❑�� License#5[50[q <br /> Vehicle Make ❑❑❑❑❑❑��ISrIJ�I❑�JIYI.1MlooddeLll:: KJR ❑❑❑❑❑❑ Year ❑�(� <br /> Type of operation X21 MFF []III with Limited Food Preparation Phone �0®�©❑ ®471gJ <br /> Penndee s Name �W7©�©[ USI®❑®�Q®©©❑❑❑❑❑❑❑❑❑❑❑❑❑❑ <br /> Address II13�' -711011811��❑©®M�2❑❑❑❑©❑®E®M❑❑❑❑❑ <br /> City LrQ'1d��L?J❑❑❑❑❑❑❑❑❑❑❑ State ©E] Zip [q]©©Ej[j] <br /> COMMISSARYINFORMATION <br /> �7 r id r <br /> Business.Namer,,�� �4�1U_�, Ur��1� .._r...�,` -�C�l_JIJ���JU�U ]±r�JL-�LrI�.-1`__JI <br /> Address illr �rlI7NJ��.7I III�I _1f l Jr�_�-SIJ?r1701�� ❑L_I❑❑❑❑❑L]L�LJL��J77If�)_t�I_ <br /> Phone <br /> L C�W❑�� LJL�100[]❑❑❑❑❑❑State a_ E Zip [GOEN� <br /> Phone (�r-�I-I <br /> Ili—1 /U_�j' ©- IS <br /> AUTHORIZATION <br /> Stanislaus County YES d NO <br /> AAUU(T�HOORIZAATION(to be completed by Commissary ovmer/authorized representative) <br /> WFyr sm ssoperator 7 of�jI�ldn I ---has permission to use the above <br /> food establishment as a commissary. The commissary can accommodate the vehicle business owner with the following <br /> functions(check all that apply): <br /> fJ_�Cutting and trimming food Cooking food <br /> 2--Rapid cooling of food <br /> 2 Washing and cleaning food e Refrigerated food storage H Dry food storage <br /> !3 Supply food product Q Supply potable water <br /> G' Ware-washing <br /> P <br /> Wastewater removal ET Waste grease removal p' Toilet& hand-washing <br /> 2 Overnight parking El Electrical hook-up <br /> Wastewater from an MFF must be discharged to a wastewater system through a grease Interceptor. g Vehicle Cleaning <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 operating day for cleaning and servicing operations. 1 agree <br /> to immediately notify the Stanislaus County Department of Environmental Resources if the vehicle business operator <br /> discontinues the use of this commissary. <br /> Commissary 0 erator's Name(Print : L <br /> Title(print . <br /> Commissary O erator's Si nature: X <br /> Date: X (� <br /> I, the above-mentioned MFF owner/operator have answered t uestions to the best of my knowledge, and will operate <br /> out of the above-mentioned commissary and report to the cc issary 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 <br /> /necessary changes. I <br /> MFF operator's Si nature X 1ilG "�l�Lvl/ / <br /> F:IdatalEnvironmental HealthlFoodlMFF formlCommissary,Applicatiorl <br />