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11 <br /> s/Fft <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 /> ty <br /> smo.p re v.ms e.n <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 g s _ _{-��; License# 4 N Z I' 9 X17 ''2 !` 1 <br /> Vehicle Make _C a"r , i -e _r — Model: REGI[ g - - -- --——- Year 1` 9 9 7 <br /> Type of operation P�j MFF ❑ MFF with Limited Food Preparation Phone 2 0 9 -4 3 0 - 6 9 0 0 <br /> Permltee's Name K y l e 0 C � of njl ni o . r ; !� <br /> Address �r——-------— ---—---a———— — —--—— --- —-- -- — <br /> 3 ' 8 '' 0 0S , p r- i n g — 0 a k D r — <br /> City M o d e s t o State C A Zip 9 5 3 5 5 <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 /> Kyle O'Connor of Mad Dogs 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 /> ❑✓ Cutting and trimming food B Cooking food B Rapid cooling of food <br /> B Washing and cleaning food Refrigerated food storage B Dry food storage <br /> P� Supply food product Supply potable water B Ware-washing <br /> B Waste water removal B Waste grease removal B Toilet& hand-washing <br /> [✓ Overnight parking PI Electrical hook-up 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 /> CommissaryOperator's Signature: X / �' - Date: X �l Z3 <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 />