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Environmental Management <br />Department <br />Marie Woodin, Director <br />0 -SA C • <br />47, <br />Lir() <br />COMMISSARY or MSU VERIFICATION <br />MOBILE FOOD FACILITY (MFF)/ MULTI EVENT VENDORS (1YEEV)/ CATERER <br />MFF/MEV/CATERER BUSINESS INFORMATION: <br />Type of Facility: P MEV 0 NIFF - Cat A El MFF- Cat. B D MFF-Cat C 0 MFF- Cat. D <br />i Food prep. at commissary) (MFF Cat B, C & D must fill out back page) <br />NIFF/MEV/Caterer Business Name: <br />License Plate Number (if applicable): a P' 019 g 3 <br />) (,\... Owner Name: <br />OCATERER <br />Owner Mailing Address: 'S kk-k-)L-4t-i5.10 \‘'t <br />Phone Number. (Work) (a.)-1) <br />City: Zip Code: iS{0 <br />Mobile: <br />I. the above-mentioned MFF/MEWCaterer Owner will operate out of the below mentioned commissary and report to the <br />commissary at least once each operating day for cleaning and servicing (As noted below) (Calcode Sec. 1142922. I will store the <br />vehicle Of applicable) at the approved commissary or another approved location. If the use of the commissary is discontinued. I <br />will notify the Environment Health Division at (9J6)875-8440 to make the necessary changes. <br />6-//(67Z <br />Senature of MFF/MEV/Caterer Owner Date <br />COMMISSARY INFORMATION: <br />Type of Facility: Z-COmmissary MSC E-16staurant aMarket <br />Commissary Business Name: /I 2/--e_7'e.* ' <br />fl Other <br /> <br />City: Z-OD/' <br /> <br />Zio"Code: ci 5 z <br /> <br />Commissary Contact Phone: <br />N Refrigerated/ frozen food storage <br />C)IN Cleaning Areas drained to wastewater/sewer system Y <br />I, the Commissary Owner/Representative, can and <br />MFF/MEY/Caterer at my permitted facility: <br />Date <br />/Signature orComrnissary Owner/Representative <br />NOTE: <br /> The signature of Commissary Owner must be a wet/original within 30 days of applying for permit NO COPIES. <br />NOTE: Use of an unapproved facility for any of above purposes can lead to revocation of your permit to operate. <br />7 Disapproved <br />Date: <br />• Approved D. Pending <br />Comments: <br />10590 Armstrong Avenue • Mather, California 95655 • fax (916) 875-8513 <br />Environmental Health (916) 875-8440 Environmental C ompliance (916) 875-8550 . <br />emd.saecountv.ner <br />Commissary Owner's Name: Ifil i keo) <br />Commissary Address: 6 2 Ve'tti-1•41'4 31" <br />(zoref) 22__e7/ 3 3 t/ <br />YgPreparation or packaging of food ?N Sewage disposal <br />\ N Potable water supply ( EKot gi<old ) / N Warewashing <br />N Garbage <br />9 N Toilet ez handwashing N Overnight parking <br />N Electrical hook-up <br />N Supplies storage <br />N Dry food storage C)Ni Supply food products <br />will provide the neeessary facilities as checked for <br />9 <br />MFF Access Hours: 6:5d / <br />the above-mentioned <br />Commissary Approval: <br />Verified by: <br />C69 30124