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COMMISSARY/COMMERCIAL KITCHEN AGREEMENT PART D <br /> ALAMEDA COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH <br /> Section 1: Pursuant to California Retail Food Code, I will notify Alameda Courity Environmental Health upon <br /> termination of this agreement or if the operator voluntarily ceases_usi_n_g-this facility <br /> li Commissary/Commercial Kitchen Owner Name <br /> Flin <br /> Street Address <br /> City&Zip Code <br /> Cell Phone# Alternate Phone# <br /> I, (Facility Owner/Manager) �H fi &/V-seo o,--- <br /> agree to provide the following services to <br /> SERVICES PLEASE CIRCLE YES OR NO: / <br /> Facilities to prepare or package food 13 YES PIK0 Dry food storage Zt ES O NO <br /> Toilet&handwashing facilities PKS O NO Waste grease removal PAS O NO <br /> Waste tank/sewage disposal RES O NO Chemical storage pnx�"s ❑NO <br /> Garbage disposal �S O NO Overnight parking(MFPU) O'YfS O NO <br /> Potable(drinkable)water supply ES ONO Enclosed overnight parking(carts) WS O NO <br /> Electrical hook-up g,<S O NO Refrigeration/frozen food storage g-Y(S O NO <br /> Equipment/utensil storage CJ4S O NO Supply food product—i.e.ice,meats aA<S O NO <br /> Warewash facility(i.e.3 compartment sink) f/"S O NO <br /> Any"NO"answer must be explained below. Additional Commissary agreements may be required: <br /> Authorized Signers(�1 1' ' //�� � C� Date 3 0�� / Phone <br /> REHS Signature Date Phone <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 co ercia kitchen has a current health permit by signing below.The <br /> establishment is in >J u+iJ County/City. <br /> An REHS signatures verifies that the facility indicated iK Section 1 meets <br /> �CALCODE: Section 11429e4�-114297. <br /> moo - SA/l eL( 0..Lq o!/� -1 / "3�s b <br /> Out County REHS Na a(Please rint) Phone <br /> 3 2� 1 9 5515 q a l a.-7 1 c e�d . m <br /> Out of co 5 re&Date Received E-mail Addres <br /> o:\operations technical\food program\unit 5\vehicles\forms\mff applications\mff application 9 9 16.docx pp a gq 0 el 2 <br />