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Department of File# <br /> yO L 4 N0 Resource Management <br /> 675 Texas Street,Ste.5500 <br /> _ Fairfield,CA• 94533 f".• <br /> T www.solanocounty.com U;.- 01 2015 <br /> ENAROWENTAL HI ALTH <br /> Environmental 1'ERf1'11T(,gFPVICES <br /> Health Division Terry Schmidtbauer, REHS <br /> (707)784-6765 Environmental Health Manager <br /> COMMISSARY AGREEMENT <br /> "Completion of this Commissary Agreement is required prior to issuance of Solano County Permit to operate a food vehicle* <br /> COMMISSARY INFORMATION <br /> I hereby certify that 1 possess a valid environmental health permit to operate a commissary as defined in Sections 114211, <br /> 114245.I, 114294-114295, 114301 and 114326 of the California Retail Food Code(Cal Code). <br /> Commissary Name: <br /> Commissary Address: f W <br /> Commissary Owner's Name: / l pK;; .Telephone: —1 <br /> Type of Facility: br-Market ❑ Restaurant �'R-Warehouse ❑ Other: r <br /> I hereby certify that the following vehicle is operating out of the above commissary: s / <br /> - - -`r`7`/-,/c <br /> Vehicle/Business Name License Plate 4 <br /> I,the commissaty owner/operator, agree to provide the following necessary facilities for the above mentioned vehicle at my <br /> permitted facility as checked below: <br /> [ ] Food preparation [ ] Utensil washing [ ] Re€rig./frozen food storage <br /> Potable water supply [ ) Dry food storage [ ] Supply/equipment storage <br /> Food product supplier Liquid waste disposal Electrical hook-up <br /> f?dVehicle/cart storage [}'Garbage disposal i.]•Restrooms <br /> I agree to notify Solano County Environmental Health of any change in the status of my operation or when this commissary <br /> agreement is lonper valid. -copy of the current health permit is provided. <br /> Commissary owner/manager /) Date <br /> ENVIRONMENTAL HEALThE'ISE//PARTMENT •,, •, ^� <br /> If the commissary is located outside of Solano County,the local environmental health jurisdiction shall verify the suitability <br /> and permit status by signing below. <br /> The commissary is located in County. <br /> cn_ �rc�rn <br /> The above establishment meets the commissary requirements pursuant to Cal Code Sections 114211, 114245.1, 114294 and <br /> �The�,/Abovc checked facilities are available at the proposed commissary. <br /> ZI 1�5 ENVIRONMENTAL HEALTH <br /> Signature f CountyHS � ��� Date DEPARTMENT <br /> /`� h SAN JOAQU1N COUNTY <br /> R:IENVHLTHISECTIONIMOBILEFOODFACII.ITIESICOMMISSARY FORM.doc 1868 East Hazelton Avenue <br /> / Stockton,California 95205-6232 <br />