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DEPARTMENT OF ENVIRONMENTAL RESOURCES <br />3600 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 im '-17FLicense # �A E g�l t !Ritalli(a❑D <br />Vehicle Make rR J T R',I_LI Model: I Fi B �� Year 2 0 2_ 2 1 <br />-C�LJ� �L:} 1 ,--�--,C=a _❑❑FIFi _ ❑ _Iii <br />Type of operation B MFF ❑ MFF with Limited Food Preparation Phone9❑❑1 LJ -©❑2 [0]- [2:j[ 52 <br />Permitee's Name r --J <br />._ul_IJai rn_1RL1 L r ez(n❑r❑.. n❑,❑F_.{n❑_.._. <br />�❑j ❑❑❑❑❑❑❑7 Iv1leAddress 2��o aIWnkeIA <br />City ❑[n�� <br />State ;fC'A..� Zip �I_�1_91_' !I8 1 <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 A 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/authorized representative) <br />Juan Ramirez <br />MFF business operator <br />food establishment as a commissary. <br />functions (check all that apply): <br />of Torterilla Ramirez has permission to use the above <br />MFF business name <br />The commissary can accommodate the vehicle business owner with the following <br />B <br />Cutting and trimming food <br />B <br />Cooking food <br />B <br />Rapid cooling of food <br />B <br />Washing and cleaning food <br />B <br />Refrigerated food storage <br />B <br />Dry food storage <br />B <br />Supply food product <br />0 <br />Supply potable water <br />B <br />Ware -washing <br />lv� <br />Waste water removal <br />B <br />Waste grease removal <br />B <br />Toilet & hand -washing <br />B <br />Overnight parking <br />B <br />Electrical hook-up <br />B <br />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 <br />Operators <br />Name (print): <br />Mark Luis Cruz <br />Title (print): Bookkeeper <br />Commissary <br />Operator's <br />Signature: X <br />Rel�- <br />. <br />Date: X I t/o i /Z -L <br />I, 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 />