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Environmental Alanagetnent Department,F.nviroamtnral Healtb Division <br /> 1059•Annsvong.Avenue a Mather•CA 95655.Ph:(916)815-8443 a Fax:(916)875-8513 <br /> wvw.easd,accaanrvxt <br /> COMMSSARY or MSU VERIFICATION <br /> MOBILE FOOD FACILITY(MFF)/Multi Event Vendors(KIEV) <br /> MFF BUSINESS INFORMATION <br /> V1'heo the mobile food facility is in-sen-icc,Mow do you opente?(cheek all That apply) <br /> C3 <br /> Dtive a RoUle-Pkasc list major stops on the back of this form <br /> o Operate in one location(provt de address): <br /> .VOTE:AAWMW& d Jotal r risdiufew rose/gray be rrgadrrd for n1kr MFF opera letatlena <br /> MEY MFF-GLA []MPF-CiLB I"-C--C <br /> a Tf ye of Fadllry• R oW Prep.at �„s�� MFF•Cat D <br /> a <br /> MFF Rusinesc Name(Name on vehicle or cart): <br /> License Plate Number: q6 11 {' — <br /> Owner Name ` r CVC, /U <br /> OWna Mailing Address: a1 a rj �j f s o ��'l'�Ciry: A C 1p Code: <br /> oPhooc Ntunber: Home afobik)_ (41f — <br /> € COWIISSARY INFORMATION <br /> o O'q b <br /> T ofFacili <br /> Ty ty: ❑Commissary ❑MSU 1WRestaurant ❑Market D Other <br /> m Commi-tary Flusioess Name:CC <br /> ,z <br /> F (:ommral <br /> issary Owner's No SAIL, C'1.� F• 1" , j.A ,�•- <br /> a Commissary Add,ess: �IT"- {t ti Ci - A e Zip Cale: J y 1 <br /> Phone Number Business) q/6)3 yy C' f rr <br /> 0 (mobile) <br /> G 770 <br /> 0 <br /> 4 the a6vre-rwrwdoned AIFF owner/operator will operate oui ojrhe above rmendoned commissary and repers to the commitaary <br /> Of least orae each operating day for cleaning and servicing(As noted below!IC HS C.Set: 114297/. 1 will score the.NFF at rhe <br /> approved commissary or another approved location. If the use of the comasissary is discontinued l Krill nodfy the <br /> Environmental Health Division at(916)d75.8440 to,wake the necessary changes <br /> ( I Preparaden er padratbg of fool "Potable wou r sapply <br /> }11 CPnnlahs psrtsae <br /> {�Eleetrlcal Sack-up Warmsattlnc I I Refr+iasmadi from road staraae <br /> I4 Toilet&baadwaabine I I Dry wag ataraae i I Soppbes norage <br /> F.j.Wslft MOW sewage disposal fscfadn fy.i,Wish crease removal 1 I Supply food pradasas <br /> I— —) AAI <br /> Signature of MFF Owner Date <br /> 1,the Commissary Ow Operator,can and K?I prov' rhe necessary faeiluies as checked for the above-mentioned MFF <br /> at ley peresitred facility: <br /> Signature of Commissary Owner Daze <br /> NOTE.The ri;latae a/Coww(ttrry 0~.-Mau,be a Wivorgdu!W"n fe Oafs-f amiyAf lo•petal NO COPIES <br /> NOTE:Use of an unapproved facility for any of above po nposes can lead to revocation of your permit to operate. <br /> Commissary Approval: 13 Pending 0.Approved '7 Dicappmved <br /> Verified by., /�a7A_4Dau t Y Rea on: <br /> A 6I ti5 Pt P q _0V C1 <br /> d £1989L89i6 44^J30eS e8E L091 l l bei^J <br /> pan�a�aa T OL £TSSSL89T6 lad WV ZZ:LZ:8 STOZ 'TT AeW <br /> s6inS S39Vd NonvsIIO OISD 310W38 03AM3M 3WI1 <br /> Al1i135S3nns (13AI3D38 XVJ : NOIIVDI3IlON ONf108NI ;.�: <br />