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c_ <br />COMMISSARY/COMMERCIAL KITCHEN AGREEMENT <br />AIAMEDA COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH <br />Commissary/ Commercial Kitchen <br />Owner Name <br />Le A /s <br />_D S <br />Street Address <br />City & Zip Cade <br />270(0Avt /ljo,t/-,wzkLo <br />Tp -4C °753 <br />Cell Phone# Alternate Phone# <br />2o9 - -(qq <br />I, (Facility Owner/ Manager) —72,21 <br />agree to provide the following services to rn ; SS D U l CL c f o US <br />SERVICES PLEASE CIRCLE YES OR NO: <br />Facilities to prepare or package food 'G*YES O NO Dry food storage N.YES O NO <br />Toilet& handwashing facilities I*YES ONO Waste grease removal OYES ONO <br />C:10 <br />Waste tank/sewage disposal ❑YES =NO Chemical storage :3 YES <br />Garbage disposal AYES ONO Overnight parking (MFPU) O YES 18�NO <br />Potable (drinkable) water supply DYES O NO Enclosed overnight parking (carts) O YES 2PNO <br />Electrical hook-up O YES ®NO Refrigeration/frozen food storage�YES O NO <br />Equipment/utensil storage 6 -YES O NO Supply food product —i.e. ice, meats O YES EfNO <br />Warewash facility (i.e. 3 compartment sink) M -YES O NO <br />Any "NO" answers must be explained below. Additional Commissary agreements may be required: <br />The printed name and signature of the facility owner/operator is required for the department to accept this <br />document <br />Print Authorized Signer Name �V 'NIS iA; 1 RC2_ Phone 26q 76 0 y4{q? <br />n7 <br />Authorized Signer Signature � '���_ <br />Date <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 commercial kitchen has a current health permit by signing below. The <br />establishment is in Anl `1 &AQy% rj County/City. <br />An RENS signatures verifies that the facility indicat in Section 1 meets CALCODE: Section 114294 —114297. <br />[[ <br />t' aLAleo.(\(\-k: Zook-blb- 3ozs <br />Out of County REHS Name (Please Print) Phone <br />�? 4 20 22 k 1 r�hare sna S��oy <br />Out of County REHS Signature & Date Received E-mail Address <br />j 7 <br />1 15 <br />