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DocuSign Envelope ID:06C7 EA30-9D56-41 F7-A40A-5AC05129E5EE <br /> Environmental Management <br /> Department <br /> Jennea Monasterio, Director <br /> O M <br /> COMMISSARY or MSU VERIFICATION FA# <br /> MOBILE FOOD FACILITY (MFF)/MULTI EVENT VENDORS (MEV)/CATERER PR# <br /> MFF/MEV/CATERER BUSINESS INFORMATION: <br /> Type of Facility: ❑MEN' ❑MFF—Cat.A ❑MFF—Cat.B ❑MFF—Cat.C ❑MFF-Cat.D ❑CATERER <br /> (Food prep.at commissary) (MFF Cat B,C&D must Till out back page) <br /> MFF/MEV/Caterer Business Name:Ash and Oil <br /> License Plate Number(if applicable): 4NZ1494 <br /> Owner Name: VENICE LABRA <br /> 3316 1 ST N. HIGHLANDS 95660 <br /> Owner Mailing Address: City: Zip Code: <br /> Phone Number: (Work) 916-223-6313 Mobile: 808-866-8806 <br /> I, the above-mentioned MFFIMEVICaterer 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, 1 <br /> will notify the Environmental Health Division at(916)875-8440 to make the necessary changes. <br /> oocuSigned by: 3/22/2023 <br /> LlUW e of MFF/MEV/Caterer Owner Date <br /> COMMISSARY INFORMATION: <br /> Type of Facility: ®Commissary ❑ MSU ❑Restaurant ❑ Market ❑ Other <br /> Commissary Business Name: VLqa-A 'n ker <br /> Commissary Owner's Name: F tc�w.c6S 5At,(.or- U-C <br /> Commissary Address: 1100 bkv j City: Scu.­10 Zip Code: 015411 <br /> Commissary Contact Phone: Q1(0- 41A- q-187 MFF Access Hours: <br /> V/N Preparation or packaging of food j/N Sewage disposal +i/N Ovemigh:parking y/N Toilet&handwashing <br /> /N Potable water supply (❑hot cold) q(/N Warewashing /N Electrical hook-up <br /> Y/N Refrigerated/frozen food storage (y/N Garbage 9(/N Supplies storage <br /> 4/N Cleaning Areas drained to wastewater/sewer system Q(/N Dry food storage Y/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 /> Sign ture of Commissary Owner/Representative Date <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: ❑ Pending ❑ Approved ❑ Disapproved <br /> Verified by: Date: Comments: <br /> 11080 White Rock Road,Ste.200 • Rancho Cordova,California 95670 . `ax(916)8755513 <br /> Environmental Compliance(916)875-8550 • Environmental Health(S'16)875-8440 <br /> www.saccountv.gov.emd.saccounty.gov <br />