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Environmental Management <br />Department <br />Marie Woodin, Director <br />COMMISSARY or MSU VERIFICATION FA # <br />MOBILE FOOD FACILITY (MFF)/ MULTI EVENT VENDORS (MEV)/ CATERER PR# <br />MFF/MEV/CATERER BUSINESS INFORMATION: <br />Type of Facility: ❑ MEV ❑ MFF— Cat A ❑ MFF— CaL B ❑ MFF—CaL C ❑ MFF- Cat D ❑CATERER <br />(Food prep. at commissary) (MFF Cat B,,CC & D must fill out back page) <br />MFFN EV/Caterer Business Name: i_t A .t �i ��wrMDfin, l O <br />License Plate Number (if applicable): LA V 17 -S <br />Owner Name: <br />Owner Mailing Address: IR v v <br />-I ® t �'1�l�ri /%✓ City: <br />Phone Number: (Work) <br />Zip Code: Ts <br />I, the above-mentioned MFFIMEVICaterer Owner will operate out of the below mentioned commissary and report to the <br />commissary at least once each operating day for cleaning and servicing (As noted below) (Calcode Sec 114297). I will 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 Healt) Division at (91W75-8440 to make the necessary changes. <br />of MFF/MEV/Caterer Owner Date <br />COMMISSARY INFORMATION: <br />Type of Facility: Commissary ❑ MSU ❑ Restaurant ❑ Market ❑ Other <br />Commissary Business Name: 1g,,, Aryt1 c_ t4,z,, y_r,/tq SVPPl y <br />Commissary Owner's Name: r>C IVC AW <br />Commissary Address: ZV40 S. Airpor )r (.ve_j City: 4S4vcV,lVt'I Zip Code: 415 -Z -OC <br />Commissary Contact Phone: ?_0 cl _ 5' ic, t— ( 6 MFF Access Hours: C: 3 ri — Z v c, .., <br />m/ N Preparation or packaging of food <br />chi <br />0 N Potable water supply ( hot <br />0/ N Refrigerated/ frozen food storage <br />,01/ N Sewage disposal <br />ff�eold) &%N Warewashing <br />LV/ N Garbage <br />6/ N Cleaning Areas drained to wastewater/sewer system &I N Dry food storage <br />i ' N Overnight parking &N Toilet & handwashing <br />jq/ N Electrical hook-up <br />& / N Supplies storage <br />49 N Supply food products <br />I, the Commissary Owner/Representative. can and will provide the necessary facilities as checked for the above-mentioned <br />MFFIMEVICaterer at my permitted facility: <br />Date <br />NOTE: The signature of Commissary Owner must be a wetloriginal within 30 days of applying for permit 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: <br />Comments: <br />11080 White Rack Road, Ste. 200 • Rancho Cordova, California 95670 a fax (916) 875-8513 <br />Environmental Compliance (916) 875-8550 a Environmental Health (916) 875-8440 <br />www.saccounty net, emd.saccountv.net <br />