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Sron <br /> DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> 3800 Cornucopia Way,Suite C,Modesto, 9494 <br /> - � Phone: 209.525.6700•Fax: 2 209.525.9.525.6774 <br /> w <br /> ww.stancounty.com <br /> Wy <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 ff Ea ',c o s E 1 G u e r o 2 0 9 License# gu f lR 3 9 4 2 <br /> Vehicle Make KIL C N S JL Model: V a r , e,i d,L � Year 2 0 2 1 <br /> Type of operation 0 MFF ❑ MFF with Limited Food Preparation Phone 2 �� 9- 7:j6 ,-j3 IU_9 _ 6 <br /> Permitee's Name LA, b e l '7V F1 g i 1 J r '&�n5 m i 1 y jVnK]EK]E <br /> Address 5 3 L e m m o n s S t 1:1EE10 <br /> City FRM. 1,v e r b a n k State iC A Zip 9 j� 3❑® 7❑ <br /> COMMISSARY INFORMATION <br /> Business Name L a C o m i s a r i a M o d e s t 0 <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 A Zip 9 5 3 5 1 <br /> Phone 2 0 9- 3 3 8 3 6 6 3 Commissary within Stanislaus County BYES ❑ NO <br /> AUTHORIZATION (to be completed by Commissary owner/authorized representative) <br /> Abel Vigil Jr& Emily Vigil of Tacos EI Guero 209 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 /> 0 Cutting and trimming food 0 Cooking food 0 Rapid cooling of food <br /> PI Washing and cleaning food B Refrigerated food storage 0 Dry food storage <br /> 0 Supply food product B Supply potable water B Ware-washing <br /> 0 Waste water removal B Waste grease removal B Toilet& hand-washing <br /> 0 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): Bookkeeper <br /> Commissary OperatorsSignature XJ/ - Date X IZZ <br /> 1, the above-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 the commissary is discontinued, I will notify the Stanislaus County Department of <br /> Environmental Resources to make the necessary changes. <br /> MFF operator's Signature: X Date: X <br /> F:\data\Environmental Health\Food\MFF form\Commissary Application.doc <br />