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PART D <br /> COMMISSARY/COMMERCIAL KITCHEN AGREEMENT <br /> Section 1: Pursuant to California Retail Food Code, I will notify Alameda County Department of <br /> Environmental Health with any changes to this agreement. <br /> Commissary/Commercial Kitchen Name Commissary/Commercial Kitchen Owner Name <br /> Commissary/Commercial Kitchen Street Address Commissary/Commercial Kitchen City&Zip Code <br /> 2goo E LAA- 5 »CJ-T-Z>1-j '�SZoZ <br /> Commissary/Commercial Kitchen Phone Number and Cell Phone Number <br /> zvg gtoq- y5-7o <br /> I,the Commissary/Commercial Kitchen Authorized Signer(printn/ame) W,41,/"k_ AEKIVINOkz— <br /> Agree to provide the following services to(print business name) e2 C D IRVD Ai4fi1 o <br /> PLEASE CHECK YES OR NO: <br /> Facilities to prepare or package food YES NO Dry food storage YES NO <br /> Toilet&handwashing facilities NO Waste grease removal NO <br /> Waste tank/sewage disposal �^' NO Chemical storage IYEri� , NO <br /> Garbage disposal rty NO Overnight parking (Yk5/ NO <br /> Potable(drinkable)water supply �O NO Enclosed overnight parking(carts) YES NO <br /> Electrical hook-up Q NO Refrigeration/frozen food storage YES NO <br /> Equipment/utensil storage YES NO Supply food product-i.e.ice,meats YES NO <br /> Ware wash facility(i.e.3 compartment sink) ES > NO <br /> Any"NO"answers must be explained belowAND may delay issuance ofthe permit.Additional Commissary agreements maybe required: <br /> Authorized Signer Signature - Date <br /> ALAMEDA COUNTY REHS SIGNATURE ONLY <br /> Section 2:is required for Commissary/Commercial Kitchen facilities located OUTSIDE of Alameda County or in the City of <br /> Berkeley <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 commercial kitchen has aurrent he Ith permit by signing below.The <br /> establishment is in 5A4 JDA-00,',J/S jd ounty/City. <br /> An RENS signature verifies that the facility indicated in Section 1 meets CALCODE:Section 1142994f�-11421917.. <br /> Out of County REHS Name(Pleas rint) �'- �-r� Phone <br /> /�'W Q-101 L9-/�fi�/ i t�✓�//� <br /> Out of County REHS Signature ate� I"2/ da_Email: L V2a a`APS ISI V Ui V� "1 <br /> REHS PLEASE EMAIL THIS FORM TO AND J <br /> o:\operations technical\food program\unit 5\vehicles\forms\mff applications\mff application 05 04 21.docx <br /> 1 -7 <br />