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Slane Ohve sDisnir,aaa <br /> CO Bary DEPARTMENT OFENVIRONMENTAL RESOURCES <br /> �h== ��• I4 I{111DyRd. 3600 Cornucopia Way,Suite O,Modesto,CA 9535&9494 <br /> � �tIIfOCi ilroyRd.CA Phone: 209.525.6700-Fax: 209.525.6774 <br /> y 109434 2006 wNrvJstancounty.com <br /> 80gp r,..144u - 1 <br /> AV <br /> I <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 Name[Ej�E� 7 <br /> [�RZ-j[��X]ir.�I�.IQ[aIU CQ�.Id � <br /> fB55 ,4 License#[gj2 Jt.71®lL-tll hf <br /> Vehicle Make ©EC]) [j2[ 0[] Model: Year L.E31[LIL7L.i <br /> Type of operation .MFF p MFF with Limited Food Preparation Phone -K'110•[ZFOI IKI <br /> Parriltee'sName ®�©®©l7Tl�_ �ltJ� LryJ��®tF_II�1�! lr 11 l I❑OY i- 1 <br /> Address �y��q�©�� r®—���7r❑y®®1❑�!L❑YII�YI4❑�❑1❑❑I❑J�❑J <br /> City L.�L [El J0E®❑❑❑❑LJI�I❑❑L-I state 9191 Zip MSIN©® <br /> COMMISSARY INFORMATION <br /> Business Name L)' /`� (J vV'y1. �ilyJIN <br /> Address �L�� _S• h.( ��(�c ` cY-_ <br /> City l`.. l G� (' C.. `f _ <br /> State /T zip <br /> 'Phone Com'missar within Stanislaus Count YES -`I <br /> -..:r 4• L."Jy " �G.t) Y Y - C7�N0 <br /> AUTHORIZATION(to be completed by Commissaryowner/authorized representative) <br /> of _/�fL) E-5T-D Ll- has permission,tonsethe above <br /> MFF.buslness opeMetdr� � -- MFFbusrneersnems, ' <br /> food establishment as.a Commissary. The commissary can accommodate the vehicle business'owner with the following <br /> functions(check all that apply): <br /> 0' Cu.'tting and trimming food of Cooking food p Rapid cooling df food <br /> B Washing and cleaning food i] Refrigerated food storage I]• Dry food storage <br /> 0 Supply food product ET Supply potable water 2 Ware-washing <br /> 0 Waste water removal 13 Waste grease removal ef Toilet'&hand-washing <br /> [j Overnight parking Ca• Electrical hook-up Q'Vehicle cleaning <br /> ^Wastewater from on MFF must be discharged to a wastewatersystem through a grease interceptor. <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 servl'cing operations. I agree <br /> to immediately notify the Stanislaus County Department of Environmental Resources If the vehicle.business operator <br /> discontinues the use of this commissary, <br /> Commissar O erator'sName tint: yf �l /rCr4 Title print): rr dJls�rU1 <br /> Commissary Operators Signature Data X <br /> I, the above.-mentioned.MFF owner/operator have answered the questions to the best of my knowledge, and will operate <br /> out of the above-mentiohed commissary and report to the commissary at least once each operating day foraleaning and <br /> servicing (as noted above). If the use of the commissary is discontinued, I will notifythe Stanislaus County Department of <br /> Environmental Resources to make the necessary change's. <br /> MFF operator's Signature:X _ tNry rVW1 � Dates X <br /> z <br /> I <br /> Fi\data\Erivironmental HealthlFoodlMFF formlCommissary Agplication.doo <br />