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fien.fa."_61I,144$1.0Cate <br />BeticIe <br /> <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 c<r:)n\ercLaJilcitchen has p current health permit by signing below. The <br />establishment Is In C\ 3 0=9' county/City. <br />An REHS signatures verifies that the facility indicated In Seaton 1 meets CALCODE: Section 114294 — 114297. <br />Q•01/4 cm-vq AV\ ( <br />Out of County REHS Name (Please Print) <br />4.i eNGNr-07_ / 21 / 2 <br />Out of County REHS Signature & Date Received <br />20ct• kolto*S02-5 <br />Phone <br />\e_ \* yOr\ove es@ S )3o0. or 5 <br />E-mail Address <br />P(2- <br />COMMISSARY/COMMERCIAL KITCHEN AGREEMENT <br />ALAMEDA COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH <br />Commissary/Commercial Kitchen <br />SToctcro.j coMmot41.-r-e k< TESk <br />Owner Name <br />RA 'a ARKETT - fout-ic.ET <br />Street Address <br />1.LO 1•4• Ek.... boiatIc--)0 Sr <br />City & Zip Code <br />-roct---rot•-), GA 1.5202 <br />Cell Phone# Alternate Phone# <br />I, (Facility Owner/ Manager) Lec:It4EL... cAtLuo - co Fout.vt)stt <br />agree to provide the following services to MLS S DO LC E Lt CA 0 US <br />SERVICES PLEASE CIRCLE YES OR NO: <br />Facilities to prepare or package food PVES 0 NO Dry <br />Toilet & handwashing facilities JECYEs 0 NO Waste <br />Waste tank/sewage disposal EYES 0 NO Chemical <br />Garbage disposal 'YES 0 NO Overnight <br />Potable (drinkable) water supply EYES 0 NO Enclosed <br />Electrical hook-up RYES 0 NO Refrigeration/frozen <br />Equipment/utensil storage EYES 0 NO Supply <br />Warewash facility (I.e. 3 compartment sink) eitYES 0 NO <br />Any "NO" answers must be explained below. Additional Commissary agreements <br />WE DoWT 0,42-ie FiSkz‘o Av1.4.-Ali6tk...cct . WE <br />food storage .YES 0 NO <br />grease removal BYES 0 NO <br />storage BYES 0 NO <br />parking (MFPU) 0 YES SNO <br />overnight parking (carts) 0 YES IgNO <br />food storage EYES 0 NO <br />food product — I.e. ice, meats 0 YES V NO <br />may be required: <br />LIRE vierST FD 01;3 Pgin0 0 C—C. Skilicklig <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 LQ0k40.- c..6,s-rt1._L-0 Phone (Lk t 5 44 — 41 2 C3- <br />Date 0 8 /2 c, I 2 414 — <br />Authorized Signer Signature .. - <br />7