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Thisform will expire with <br /> Slanr ' our commissary on the DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> ' date below 3800 Cornucopia way,suite C,Modesto,CA 95358.9492 <br /> Phone: 209.525.6700•Fax: 209.525.6774 <br /> EXPIRATION www.stancounty.com <br /> DATE 6 a9. _2-Z <br /> COMMISSARY VERIFICATION FOR 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 /> -- — �_ License# 4 R H 4 3 3 1 <br /> Business Name. E' 1 T a c o ,—' S. o f -_. <br /> 7-' — Year 2 0 2 0 <br /> Vehicle Make -S. P C N S Model V a ',r > e^"d . —, _ <br /> Type of operation ❑MFF 0 MFF with Limited Food Preparation Phone 6 5 0 - 2 1 8 - 1 7 8 5 <br /> Permitee'sName A n_d_ri a s . S a l a d 'o <br /> Address 1_7 2 9 W, a 1_.,p o l.l_e D_ r i v..e_ --.-_-- <br /> - -- _ <br /> City M o._d e s t- o State c A Zip 9 5 3 5 8 <br /> COMMISSARY INFORMATION <br /> - - <br /> Business Name L -a __. C o _m i s , a._r -i a, M o d _t: a _s, o__--_ <br /> Address 5 0 0 7 t h S t 3 t e D <br /> City M o _d ,-e. s_ t_ o State 1 C A', Zip 9 5 3 5 4 <br /> Phone 2 0 9 -3 3 8 -3 6 6 3 Commissary within Stanislaus County [EYES ❑ NO <br /> AUTHORIZATION(to be completed by Commissary owner/authorized representative) <br /> Andres Salgado of EI Taco Spot has permission to use the above <br /> MFF business operator MFF business name <br /> food establishment as a commissary. The commissary can accommodate the vehicle business owner with the following <br /> functions(check all that apply): <br /> ❑, Cutting and trimming food ❑ Cooking food ❑ Rapid cooling of food <br /> ❑ Washing and cleaning food ❑ Refrigerated food storage ❑ Dry food storage <br /> ® Supply food product ® Supply potable water ® Ware-washing <br /> ® Waste water removal ® Waste grease removal ® Toilet&hand-washing <br /> ❑ Overnight parking ❑ Electrical hook-up ® Vehicle cleaning <br /> • wastewater from an MFF must be discharged to a wastewater system through a grease Interceptor. <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. I 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 Operator's Name(print): Alfonso Meraz itle(Print):Manager <br /> Commissary Operator's Signature:,X Date: X <br /> I, the above-mentioned MFF owner/operator have ans eyed 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 changes. �f <br /> MFF operator's Signature:X — r(dre5 �� g G V O Date: X <br /> K\2009 Working\Commissary TF\Commissary Application.doc <br />