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Slon' DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> 3800 Cornucopia Way,Suite C,Modesto,CA 95358-9494 <br /> Phone: 209.525.6700•Fax: 209.525.6774 <br /> www.stancounty.com <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 /> Business Name A j u u a M e x i c a n F c o d License# 1 2 0 1 7 E 3 <br /> Vehicle Make F o r d Model: V a n Year 2 0 0 6 <br /> Type of operation 0 MFF ❑ MFF with Limited Food Preparation Phone 4 1 5- 8 8 7 -8 9 0 7 <br /> Permitee's Name F& u a n�r M i n j a r e s <br /> Address 2 7 0 9 P a r k d a l e D r <br /> City M o d e s t o State C A Zip 9 5 3 5 8 <br /> COMMISSARY INFORMATION <br /> Business Name L a C o m i s a r i a M o d e s t o <br /> Address 1 2 1 1 S 7 t h S t r e e t <br /> City M o d e s t o State C p Zip 9 5 3 5 1 <br /> Phone 2 0 9- 3 3 8 -3 6 6 3 Commissary within Stanislaus County B YES ❑ NO <br /> AUTHORIZATION (to be completed by Commissary owner/authodzed representative) <br /> Juan Minjares of Ajuua Mexican Food 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 /> B Cutting and trimming food B Cooking food B Rapid cooling of food <br /> B Washing and cleaning food 0 Refrigerated food storage B Dry food storage <br /> �? Supply food product B Supply potable water B Ware-washing <br /> B Waste water removal 0 Waste grease removal B Toilet& hand-washing <br /> B Overnight parking B Electrical hook-up 0 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): Mark Luis-Cruz Title(print): office Admin <br /> Commissary Operator's Signature: X Date: X 9— g�j <br /> I, the abovfa-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 he c missary is discontinued, I will notify the Stanislaus County Department of <br /> Environmental Resources to make th ces ry changes. <br /> MFF operator's Si nature: X Date: X <br /> F:\data\Environmental Health\Food\MFF form\Commissary Application.doc <br />