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I <br /> S10,7 ro, Oliv s Disuiuc au, <br /> a sar DEPARTMENT OF ENVIRONMENTAL RESOURCES <br /> 14 filmy tid, 3860 Cornucopia Way,Suite b,Modesto,CA 95358-9494 <br /> Tirlock,CA 95380 Phone: 209.525.6700•Fax; 209.525.6774 <br /> 2tJ9.634 29Ri1 <br /> vMw..stancounty.com <br /> my , <br /> COMMISSARY VERIFICATION FOR MOBILE FOOp 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® OC GllArl vltW ,4 Ucensa#��L! JtZ I�IL�IhJ <br /> Vehicle Make Model: [0gjD r�.��IIJu�❑�❑� Year <br /> Type of operation Q9,MFF [ MPF With Limited Food Preparation Phone I� t��u- 0©.©EI®KI <br /> Permiteei'sName 1I21MIM110 ?.I1DttJL�IIISlLrlJ�®®L4JIJI 1L_1LeILl��1_I®�� <br /> Address I p��� i�07i®i©r��©�0y0®®�IJLI�0�00� <br /> City 1_t7LS1JOl1��©®LJI_It�l�lrl❑LI� state Zip ®�©® <br /> COMMISSARY INFORMATION <br /> Business Name, <br /> Address L!' J -._.7 • /L,_t /�(� �_ _. _ <br /> City Tc t l' G J State e14 zip 6/'S � <br /> Phone ;�L `„ "l J _ -�4rUv Commissary within Stanislaus County - YES ]ANO <br /> AUTHORIZATION(to be completed by Commissary awar/authorized representative) <br /> J�Frt- MG,)r;CrlhL1 <br /> . i.. <br /> of_H W5T'D Lt,C l� has permission,to use the above <br /> MFFbusrness operefdi- ' " "" MFFbusrness name ' <br /> food establishment as a commissary. The commissary can accommodate the vehicle buslness owner with the following <br /> functions(check all that apply): <br /> p' Cutting and trimming food Cooking food Q Rapid.cooling of food <br /> 0 Washing and cleaning food [ Refrigerated food storage CT Dry food storage <br /> 0 Supply food product 0" Supply potable water 2 Ware-washing <br /> i3 Wastewater removal i3 Waste grease removal if Toilet&hand-washing <br /> iEj Overnight parking 2 Electrical hook-up d Vehicle cleaning <br /> Wastewaterfrom an MFF must ba 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 foot) <br /> facilities are to report to the cornmissary 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 thls commissary. <br /> Commissar Operator's Name(print).. TItI rint:U <br /> Commissary Operators Signature Date X <br /> I, the above-mentioned.MFF ownerloperator have answered the questions to the best of my knowledge, and will operate <br /> out of the above-mentiohed commissary and report to the commissary at'least once each operating day fcncleanng 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 neces`sa1ryohariges. <br /> MFF operator's Signature;X - C% r41.e� Date.,X 2o <br /> F:AdatMEnvironmental Health\Food\MFF forrnNCommissaryAppl'ioationAcc <br />