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Environmental Management , <br /> Department <br /> Val F. Siebal, Director <br /> 444 D1i5� . <br /> �4i aN\ <br /> COMMISSARY or MSU VERIFICATION Fan '17/3'1 <br /> MOBILE FOOD FACILITY(MFF)/MULTI EVENT VENDORS(MEV)/CATERER PR# 96Z 2 <br /> MFF/MEV/CATERER BUSINESS INFORMATION: <br /> Type of Facility: ❑MEV ❑MFF-Cat A ❑MFF-Cat.B ❑MFF-Cat C ❑MFF­Cat.D []CATERER <br /> (Food preµat commissary) (MFF Cat B,C&D must fill out back page) <br /> MFF/MEV/Caterer Business Name: N) <br /> License Plate Number(if applicable): <br /> Owner Name: Y1QC J-- woo <br /> Owner Mailing Address: p3 City: , t Zip Code: <br /> Iltp <br /> Phone Number:(Home) a� 3 -O7y10 Mobile: ��Ih an <br /> I,the above-mentioned MFF/MEV/Caterer 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 114297). I will storethe <br /> vehicle(if applicable)at the approved commissary or another approved location. If the use of the commissary is discontinued,I <br /> will notify the Envlron nfal Heahh Division at(916)8754440 to make the necessary changes. <br /> Signature of MFF/MEV/Caterer Owner - Date <br /> COMMISSARY INFORMATION: <br /> Type of Facility: VCommissen ❑ MSU ❑Resta t El Market El Other <br /> Commissary Business Name: Q [.e Mier` <br /> Commissary Owner's Name: /L/U <br /> Commissary Address: 3 an V U S City: "Mj% Zip Code: q s� <br /> Phone Number: (Business) "1 I 7 3 Mobile: <br /> f3-rreparatioa or packaging of rued Potable water supply [3,4`0vtrnight parking <br /> VElectrical hook-upWarewashiog EX Refrigenled/frown food storage <br /> tirToilet&handwashing 12f- Dry food storage 174supplies storage <br /> �v"S'este lank/sewage disposal facilities 011 Waste fires w removal _J�K Supply food products <br /> 1,the Commissary Owner.can and will provide the necessary facilities as checked jar the above-mentioned MFF/MEVICaterer of <br /> my permitted facility: <br /> Signature of Commissary Owner Date <br /> NOTE: The signature of Commissary Owner must be a wer/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 /> Commissary Approval: ❑ Pending "pproved ❑ Disapproved <br /> Verified by: r .T�lorrou Date: 1/36/17 Comments: <br /> 10590 Armstrong Avenue a Mather,Califomia 95655 a fax(916)875-8513 <br /> Environmental Compliance(916)8754550 a Environmental Health(916)875-8440 <br /> www.samountv.net•emd eoccountr.nef <br />