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d11 i)Ti kl-11 If 1 2 <br />m <br />} 1flLiLLlJ <br />zio [ 91ff Tr.377 I <br />Address <br />City t e ircil a IL I state rc—Irii-7 <br />Business Name L a Comisaria Modesto <br />Address 1 2 1 1 S. 7th Street <br />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 />in, h. ine <br /> <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 1 T 117circY. s 171 a Iry1itiI1_r -11_117 <br />Vehicle Make e iLl]Model: <br />License # 2 —J1L4 114 .114 110-1[-6 <br />Year 1,-1T1 9 i7-8-7T 1 <br /> <br />Type of operation MFF Phone 2 MFF with Limited Food Preparation 0 91 -1-5117175-,-Lijr-T4-15-7 75-1 <br />Permitee's Name rli 17 <br />COMMISSARY INFORMATION <br />City Modesto <br />Phone 2 0 9-3 3 8-3 6 6 <br />State C A Zip 9 5 3 5 1 <br />3 Commissary within Stanislaus County 2 YES D NO <br /> <br />AUTHORIZATION (to be completed by Commissary owner/authorized representative) <br />Maria Salazar of Tacos Nayarit 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 <br />functions (check all that apply): <br />business owner with the following <br />2 Cutting and trimming food 2 Cooking food 2 Rapid cooling of food <br />2 Washing and cleaning food 2 Refrigerated food storage 2 Dry food storage <br />2 Supply food product 2 Supply potable water 2 Ware-washing <br />2 Waste water removal 2 Waste grease removal 2 Toilet & hand-washing <br />2 Overnight parking 12 Electrical hook-up 2 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 Operator's Signature: X <br /> <br />Date: X //////22... <br /> <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