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;DowSign, Envelope ID: 06C1EA30-9056-41F7-A40A-5AC05129E5EE <br />Environmental Management <br />Department <br />Jennea Monasterio, Director <br /> <br />COMMISSARY or MSU VERIFICATION <br />MOBILE FOOD FACILITY (MFF)/ MULTI EVENT VENDORS (MEV)/ CATERER <br />FA # <br /> <br />PR# <br /> <br />MFF/MEV/CATERER BUSINESS INFORMATION: <br />Type of Facility: 0 MEV 0 MFF — Cat. A CI MFF — Cat. B El MFF —Cat. c El MFF- Cat. D ECATERER <br />(Food prep. at commissary) (MFF Cat B, C & D must fill out back page) <br />MFF/MEV/Catcrer Business Name: Ash and Oil <br />License Plate Number (if applicable): 4NZ1494 <br />Owner Name: VENICE LABRA <br />Owner Mailing Address: 33161ST City: N. HIGHLANDS 95660 Zip Code: <br />808-866-8806 <br />1, 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 store the <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 Environmental Health Division at (916)875-8440 to make the necessary changes. <br />DocuSigned by 3/22/2023 <br />VL1AA Gt. Wtiftlure of MFF/MEV/Caterer Owner Date <br />COMMISSARY INFORMATION: <br />Type of Facility: Commissary D msu Li Restaurant E Market 0 Other <br />Commissary Business Name: ItiJoac S-tociNcy, <br />Commissary Owner's Name: ?.taxgeC Sit,tuk4y._ <br />Phone Number: (Work) 916-223-6313 Mobile: <br />Commissary Address: ‘100 1:A.vj City: S 0-4-d CA"e-'4 0 Zip Code: °61:0 <br />Commissary Contact Phone: 44,- con MFF Access Hours: <br />V/ N Preparation or packaging of food <br /> <br />N Sewage disposal <br />4 / N Potable water supply ( 0 hot <br /> <br />14.1 cold) N Warewashing <br />Y / N Refrigerated/ frozen food storage <br /> of/ N Garbage <br />N Cleaning Areas drained to wastewater/sewer system y, N Dry food storage <br />N Ovemigh: parking \i/ N Toilet & handwashing <br />N Electrical hook-up <br />N Supplies storage <br />Y I N Supply food products <br />I, the Commissary Owner/Representative, can and will provide the necessary facilities as checked for the above-mentioned <br />MFF/MEV/Caterer at my permitted facility: <br /> <br />31 Vol <br />Date <br /> <br />Sign ture of Commissary Owner/Representative <br /> <br />NOTE: The signature of Commissary Owner must be a wet/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: 0 Pending 0 Approved D Disapproved <br />Verified by: Date: Comments: <br />11080 White Rock Road, Ste. 200 • Rancho Cordova, California 95670 • 'ax (916) 875-8513 <br />Environmental Compliance (916) 875-8550 • Environmental Health (516) 875-8440 <br />www.saccountv.gov • emd.saccounty.gov