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this form wii. -pire with Aar our commiss..., on the <br />date below <br />EXPIRATION <br />DATE zo <br />30.14, . Baal <br />DEPARTMENT OF ENVIRONMENTAL RESOURCES <br />3800 Cornucopia Way, Suite C, Modesto, CA 95358-9492 <br />Phone: 209.525.6700 • Fax: 209.525.6774 <br />www.stancounty.corn <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 NameRE kiiiihjEDE. gallEEMETR:1_1 License #0,:gfigErialojEfli Vehicle Make 01:1. IE'r1711117-3 j Model: 1-1717 Tigifi:11—..11E1001-10 Type of operation o MFF MFF with Limited Food Preparation <br />Phone grOn rojr214-frolgE31 Permitee's Name 11:1,7i,JETIL 4_e 1 ErnirattlE1201:1 Address 7 jrillriarij <br />City JJ <br />—11-11 <br />ETICIETall@RIELEJEGEEJ-DattiEJONLIDDOEC1 <br />COMMISSARY INFORMATION <br />at JrcliEl. <br />allOODED State ICE:j Zip L.21,N,E.1 <br />Business Name r-lLgElsji rn <br />Ras jira§di tiLoir JOE1Doccoo State RED Zip Ercaligrj.1 )Eni:-0 3 _II 8 I-13_ f6-1; 6 :rill Commissary within Stanislaus County X YES El NO AUTHORIZATION (to be completed by Commissary owner/authorized representative) <br />Danielle Sanders of Wandering Barista MFF business operator <br />MFF business name has permission to use the above <br />food establishment as a commissary. The commissary can accommodate the vehicle business owner with the following functions (check all that apply): <br />11 Cutting and trimming food LiCooking food Washing and cleaning food <br /> <br /> Rapid cooling of food D Refrigerated food storage =_1- Supply food product <br /> <br /> Dry food storage IX Supply potable water X Waste water removal Ware-washing [1] Waste grease removal <br />Toilet & hand-washing Overnight parking <br />LI Electrical hook-up Wastewater from an MFF must be discharged to a wastewater system through a grease interceptor. Ed Vehicle cleaning <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 ..-fi to immediately notify the Stanislaus County Department of Environmental Resources if the vehicle business operator scontinues the use of this commissary. <br />Ccmmissa Operator's Name ( rint <br />ommissary Operator's Signature: X <br />Date: X <br />,the above-mentioned MFF owner/operator have a swered the questions to the best of my knowledge, and will operate <br />xst of the above-mentioned commissary and report to the commissary at least once each operating day for cleaning and <br />ervicing (as noted above). If the use of the commissary is discontinued, I will notify the Stanislaus County Department of Environmental Resources to make the nec changes. <br />IFF operator's Signature: X <br />Date: X -2 - 2- / <br />'2009 Working \Commissary TF\Commissary Application.doc <br />Year irfgaklJ <br />City <br />Phone <br />Address 175325110EIEFITIEgif—t1 ONEEOLDOECIDEtriDEILTE DEIEvialEJEMODOLEEILIT3 <br />Arturo Vaca Title ('Tint): Mana er <br />