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S7W C <br />i /r/zJ>Date: <br />J Da*e Received:| PR#:PE: <br />REV DATE: 1/10/2020 <br /> <br />(5) <br />FOR OFFICE USE ONLY <br />i FA#: <br />; REHS: <br />i Received By: <br />! Date: <br />CONTRA COSTA.. <br />HEALTH SERVICES <br /> Ato/a Date: <br />TO BE COMPLETED BY COlWMERCIAUPRODUCTlON KITCHEN OWNER OR OPERATOR <br />Iyes Ino <br />□T Ice machine or cooling equipment <br />SI Potable water <br /> Garbage and refuse disposal <br />£1 Dry food/equipment storage <br />El Chemical storage <br />Of Restroom with hand washing facilities <br />Print Name:. <br />Email: -fe, <br />; include a copy of a valid health permit. I certify that the business named in Section 1 is <br />; operating out of the above Gojumercial/Production Kitchen. <br />Owner/Manager Signature: Print Name: Date: 7 <br />3. OUT OF COUNTY PRODUCTIoTl KITgHEN (SIGNED BY AGENCY WITH JURISDICTION) <br />I The above listed Commercial/Production Kitchen is permitted in County. <br />' The above checked (see section 2) requirements are available at the proposed Production <br />I Kitchen/approved facility. <br />i Include a copy of valid Environmental Health (EH) Permit and obtain a signature from an <br />| authorized EH inspector from that County. <br />'[ REHS Signature: 17^- <br />Telephone: Fi C’-f <br />CONTRA COSTA <br />ENVIRONMENTAL HEALTH DIVISION <br />2120 DIAMOND BOULEVARD, SUITE 100 <br />CONCORD, CA 94520 <br />(925) 608-5500 (925) 608-5502 fax <br />EMAIL: cocoeh@cchealth.orq <br />WEBSITE: http://cchealth.orq/eh <br /> <br />C O M M E RCI AlL/P RODUCTIoTi KIT C H EN AGR E E WENT <br />FOR TEMPORARY FOOD EVENT VENDORS <br />1, TO BE COMPLETED BY FOOD BOOTH OPERATOR <br />| Owner Name: jF°od Booth Namep.^ <br />I Mailing Address (C^. State, ZipY^ g <br /> <br />Telephoney^QtY ___________________I ErnailIc&tfLcom <br />I hereby declare that the above information is current, true and correct to the best of my knowledge <br />I and agree to use the Commercial/Production Kitchen in accordance with the California Health and <br />: Safety Code. <br />Signature: Print Name: /^^{A <br />2. <br />; FACILITY CURRENTLY PERMITTED BY HEALTH DEPARTMENT: <br />Commercial/Production Kitchen Name: (2A XtXa J <br /> <br />Facility Address (City, State, Zip): L/T2/ <br />; Owner NameFA/'/xao ^'6^I phone: 2^ WW I Email: <br />, I will provide the above-namiofood booth operator access to the following (if available <br />Ef Hand washing facilities <br />Ef Food preparation area <br />Gf Food preparation sink <br />3-Compartment warewash sink <br />21 Refrigeration/Freezer storage <br />GJ Cooking equipment and ventilation hood <br />If Commercial/Production Kitchen holds a valid Environmental Health Permit to operate,