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COMMISSARY/COMMERCIAL KITCHEN AGREEMENT <br />ALAMEDA COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH <br />Commissary/ Commercial Kitchen <br />Owner Name <br />� <br />C\0,(Af Ua(I, 0- ���I-�Gt ��s <br />1 <br />-W&K Addfess <br />city & Zip Code <br />SZl S e, <br />©l 95� Yd <br />Cell Phone#, ,, Alternate Phone# <br />1, (Facility Owner/ Manager) O <br />agree to provide the following services to [ , A SGi <br />SERVICES PLEASE CIRCLE YES OR NO: <br />y <br />Facilities to prepare or package food MES 8NO Dry food storage 'OYES ONO <br />Toilet & handwashing facilities ;WYES O NO Waste grease removal O YES XN0 <br />Waste tank/sewage disposal F'ES n NO Chemical storage B YES *NO <br />Garbage disposal O YES eg! NO Overnight parking (MFPU) O YES 1NO <br />Potable (drinkable) water supply *? ES O NO Enclosed overnight parking (carts) 13 YES 0<N 0 <br />Electrical hook-up O YES IFNO Refrigeration/frozen food storage MYES ❑ NO <br />Equipment/utensil storage 19r?ES O NO Supply food product— i.e. ice, meats O YES e9NO <br />Warewash facility (i.e.3 compartment sink) AYES ❑ 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 />� J / <br />Print Authorized Signer Name A A 4 e /� Phone <br />Authorize_dSignerSignature Date __ye z02 <br />Section 2: is required for Commissary Commercial Kitchen facilities located OUTSIDE of Alameda County or in <br />the Irity 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 Zsa_ 02\ n (� County/City. <br />An RENS signatures verifies that the facility indicated in Seco fl 1 meets CALCODE: Section 114294 _ 114297. <br />�c�ec�r\r�� L'�n�rnlfS 'LIQ—bl b- 325 <br />Out of County REHS Name (Please Print) Phone <br />3 Z 2O k\ �v��o�reSC�_ <br />Out of County REH5 Signature & date geceived E-mail Address <br />L_ <br />15 <br />