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COMMISSARY/COMMERCIAL KITCHEN AGREEMENT PART D <br /> ALAMEDA COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH <br /> Section 1 : Pursuant to California Retail Food Code, I will notify Alameda County Environmental Health upon <br /> termination of this agreement or if the operator voluntarily ceases using this facility <br /> Commissary / Commercial Kitchen Owner Name <br /> in alms <br /> �. <br /> Street Address City & Zip Code <br /> 2 s IT a <br /> juz ? 9 337 <br /> Cell Phone# 'Alternate Phone# <br /> I , ( Facility Owner/ Manager) 4 UfyS �� o� <br /> agree to provide the following services to r Lo W ( a /7 �� e 5 <br /> SERVICES PLEASE CIRCLE YES OR NO : � � <br /> Facilities to prepare or package food 0 YES � O <br /> Dry food storage 'YES 0 NO <br /> Toilet & handwashing facilities PES 0 NO Waste grease removal W4 0 NO <br /> Waste tank/sewage disposal PES 0 NO Chemical storage RnA�`s O NO <br /> Garbage disposal VS Cl NO Overnight parking (MFPU) '�., ,,_�- 0 NO <br /> Potable (drinkable) water supply ES 13 NO Enclosed overnight parking (carts) ' S 0 NO <br /> Electrical hook-up gXfS 0 NO Refrigeration/frozen food storage §PYfS 0 NO <br /> Equipment/utensil storage gXfS 0 NO Supply food product — i.e. ice, meats P " 0 NO <br /> Warewash facility ( i.e. 3 compartment sink) v -- 0 NO <br /> Any "NO" answers must be explained below. Additional Commissary agreements may be required : <br /> Z, <br /> Authorized Signer /Ytl o9d Date vZl / Phone <br /> REHS Signature Date Phone <br /> Section 2 : is required for Commissary/Commercial Kitchen facilities located OUTSIDE of Alameda County or in <br /> the City of Berkley <br /> If the proposed facility is located outside of Alameda County and Berkeley, the local Environmental Health Department <br /> shall verify that the commissary and/or co ercia kitchen has a current health permit by signing below. The <br /> establishment is in iJ uiil County/City. <br /> An REHS signatures verifies that the facility indicated iA Section 1 meets CALCODE: Section 114294 — 114297 . <br /> S e v +*! 5'A P) a( a.t.q ?� v P 3 �G5 Z <br /> Out County REHS Na e (Pleas Phone <br /> 9 SS iq nz 4, I et.*7 J c e � d . <br /> Out of Co re & Date Received &mail Addres <br /> o:\operations technical\food program\unit 5\vehlcles\forms\tuff applications\mff application 9 816.docx <br />