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CONTRA COSTA WIRONMENTAL HEALTH DIVISIOICE1 <br /> 2120 DIAMOND BOULEVARD,SUITE 200go CONTRA COSTA CONCORD,CA 94520 <br /> HEALTH SERVICES (925)692-2500 (925)692-2502 FAX AUG 21 <br /> http://cchealth.org/groups/eh <br /> OUTSIDE OF COUNTY COMMISSARY AGREENMSEFMCES <br /> I hereby declare that I hold a valid environmental health permit to operate a commissary as defined by the California Retail Food Code,Chapter 10. <br /> *Note: Include copy of valid environmental health or State permit. <br /> (26 rn epeA a �_ <br /> Commissary Name ��t-p <br /> AI D D ac r cG N r, IN Py <br /> Commissary Address <br /> City,State,Zip <br /> Telephone FAX <br /> hereby declare and certify that �'L with license plate 40C/'lo_?4is operating out of the above <br /> Vehicle Name License Plate# <br /> commissary.This commissary agreement is valid until <br /> Date <br /> I understand and agree to provide the following requirements: (Check all that apply) <br /> Mobile food facility storage area. <br /> Food preparation area. <br /> Utensil washing area. <br /> L Liquid waste disposal to: 4 Mop Sink 151� Wash Pad <br /> Garbage and rubbish disposed of in a sanitary manner. <br /> Hot and cold potable water, protected from potential back flow, available for the mobile food facility. <br /> Approved restrooms available-for the—mobile food facility operators. — — -- <br /> �; ❑ Sufficient food/utensil storage space designated for each mobile food facility. <br /> I will notify Contra Costa En ' onmental Health by written document,of any change in the status of my operation, my environmental health permit,or <br /> when this commissary agre e <br /> Signatur (Commissary Represe / ate <br /> (((? # /4-0 — - <br /> Print Name(Commissary Representative) (/• f <br /> ENVIRONMENTAL HEALTH DEPARTMENT: <br /> If commissary establishment is outside of Contra Costa County, the local environmental health jurisdiction shall verify current <br /> commissary health permit by signing below. Food establishment is in_5u.A County, <br /> Facility above meets California Retail Food Code, Section 114294-114297 and 114326 commissary requirements. The above <br /> checked requirements are available at the proposed commissary. <br /> Signatrre(County RENS) (Date I <br /> A("' – S.4(ZiD <br /> Print Name(County REHS) Telep'one <br /> Revised 09/10 <br />