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File # <br />flo /b <br />Vehicle / Business Name: <br />Commissary Name: <br />Commissary Address: <br />Telephone: <br /> Other: MarketType of Facility: <br />Commissary TJwner/ Manager <br /> <br />DateSignature <br />[/| Utensil washing <br />[✓] Dry food storage <br />[y] Liquid waste disposal <br />[/] Vehicle / cart storage <br />[V] Refrig. I frozen food storage <br />[ /] Supply /equipment storage <br />[/] Electrical hook-up <br />[■4 Garbage disposal <br />4 <br />4 <br />Department of Resource Management <br />675 Texas Street, Ste. 5500 <br />Fairfield, CA • 94533 <br />www.solanocounty.com <br />Environmental Health Division <br />(707) 784-6765 <br />1 certify that, to the best of my knowledge, the above information is true and that 1 will comply with all applicable local, <br />city, county, and state requirements. <br />Signature Date <br />E.H. DEPARTMENT AUTHORIZATION (REQUIRED) <br />The following information shall be completed by the local E.H. Department if the food establishment / commissary is <br />located outside Solano County: <br />I, the commissary owner/operator, agree to provide the necessary facilities for the above-mentioned vehicle at my <br />permitted facility as checked below: <br />Restaurant <br />_________County. <br />■■ ~ yXygg no (explain below):The food establishment / commissary is located in-------------. <br />The above establishment is in good standing with the local E.H. Department? <br />Vehicle / Business Operator: <br />Print Name <br />101 W(J <br />CaweC <br /> <br />Commissary Owner’s Name: cL-------------------- <br /> Warehouse <br />COMMISSARY AGREEMENT <br />* Completion of this Commissary Agreement is required prior to issuance of Solano County Permit of a Food Facility. * <br />[/[ Food preparation <br />[•4 Potable water supply <br />[■/] Food product supplier <br />[7] Restrooms <br />1 agree to notify Solano County Environmental Health of any change in the status of my operation or when this <br />edrnmissgryagreement is no longer valid. A copy of the current health permit is provided. <br /> <br />Date <br />Out of County REHS: 7y\>v»<.0 <br />Print Name