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a <br />�lAeR <br />Environmentel Management 4 <br />0epartment <br />Jennca <br />Monasterio, Director <br />COMMISSARY or MSU WRIFICATION FA# <br />MOBILE t•OOU FACILITY (MFF)/ MULTI EVENT VENDORS (MEY)l CATERER PR'# <br />MFF/MEWCATERER RUSINESS INFORMATION: <br />Typeof PaeiEly:❑NIEV ❑NPN❑ coin CAFERI.R <br />❑mPp-cai6 ❑a1rP-coir. <br />atrP-c,ia ❑ <br />(l'ubd prep, al cnmmiamrv) (MpF Cal6,C&Root fdiout brrk gaga/ <br />\IFF;\4EV!cntcrer Business Name: <br />�t I <br />License Plate Number (ifupplirnble): <br />Owner Name: _ O <br />Owner Mailing Address: --'U'/ , _LLV&..Zip Cndc: ._ <br />Phone Number. (Work)Q ,� Mobile: <br />1, Nie above-..cnlimred .1IFF1AI1A?EV1Caterer Owner will operate out if the below mentioned rnnrmissary and report to the <br />rnnunissap• at lendonce each operating day for cleaning and servicing (As noted below) (Calcode See. 114297). 1 will store the <br />vel+iele (if applicable) at Nte approved commissary or another approved location. If the ase of III, commesanm is discontinued, 1 <br />will nolifj, the;E Hcoltb Division ar (916)875-8400m make tl+e neceesap• changes. <br />C\{(1CAV1 ryll/LZ Date <br />Signature of MFF/MEV/Caterer Owner <br />COMMISSARY INFORMATION: <br />Type of Facility: 91 ommissary ❑ MSU ❑ Restaurant ) ,,y❑_ Market ❑ Other <br />Commissary Business Name. u U I `i C_bk LA S <br />Commissary Owner's Name: p 1 4- <br />Commissary Address:�� r�', try(,(.( �(- <br />Put: ( Zip Code; VL <br />Commissary Contact Phone: 7 (� ! UC 2j—�, ('�` ' t -f WF Ace ss Hours: <br />T N Preparation or packaging of 6tn1 <br />/ N Sciage disposal /1' 16 overnight puking N Toilet & handeashing <br />Y N Potable slater supply I ❑hot ❑ mid) IN Warewushing tyy/� Electrical hook-up <br />Y N Refrigerated/ frozen I'oud storage Y N Garbage �w I N Supplies storage <br />N Cleaning Areas drained to nuslewatertseINV syste Y N Dry food stooge (1J' 6N Supply food products <br />1, Nie Cotnmisrare Owner/Renresenmlive. can and will provide the mvrssary facilities as checked for the above-mentioned <br />MFFlAIEV/Calerer at my pennille dif <br />Sigingture of�Co t mt mi'g�, tvner/Representative Date <br />NOTE: The .signaiare of Commissary Owner oust be a walorigiral within 30 dans of opplving for permit. NO COPIES. <br />NOTE: Ilse of an unapproved facility for any of above purposes can lead to revocation of your permit to operate. <br />Commissary Approval: ❑ Pending ❑ Approved ❑ Disapproved <br />Verified by: Date: Comments: <br />11080 White Rork Rd., Ste. 200 - Rancho Cordova, CA 05670 • in (916) 675-8513 <br />Emiraamenlal Comphance(916)8756550 • Environmental Health 1916) 87&8440 <br />W..... ,.imm"I np_mv" go, <br />