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Department of <br /> Record# <br /> 50LgN <br /> On _ <br /> Resource Managemcn —4 � \c_- <br /> 675 Texas Street,Ste.5500 <br /> Fairfield,CA•94533 <br /> o �v.solanocounty.com <br /> O V N< <br /> Environmental <br /> Health Division Edmond Strickland,REHS <br /> (707)784-6765 <br /> Environmental Health Manager <br /> *Completion of this Commissar COMMISSARY AGREEMENT <br /> Agreement is required prior to issuance of Solano County Permit of a Food FacilitY . <br /> Vehicle/Business Name: <br /> Commissary Name: <br /> Commissary Address: 1-71711-77' U /0A-1 57— <br /> Commissary <br /> TCommissary Owner's Name: ��I�RJ/ (� Telephone: 02-01 (F: 6-W <br /> Type of Facility: ❑ Market ❑ Restaurant ❑ Warehouse ❑ Other: <br /> 1,the commissary owner/operator,agree to provide the necessary facilities for the above mentioned vehicle at my permitted <br /> facility as checked below: <br /> [y'Ftood preparation [416-tensil washing [ ]Refrig,/frozen food storage <br /> [ ] Potable water supply [ ]Dry food storage [ ]S <br /> .yply/equipment storage <br /> [ ] Food product supplier [ ]Liquid waste disposal [ 'lee I hook-up <br /> [ ]Restrooms [v]' ehicle/cart storage (4,52Fbage disposal <br /> I agree to notify Solano County Environmental Health of any change in the status of my operation or when this commissary <br /> agreement is no longer valid. A copy of the current health permit is provided. <br /> 11312-3 <br /> Commissary Owner/Manager 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 locat <br /> —outside Solano Countv: <br /> The food establishment/commissary is located in sa,( J Ocq U County. <br /> The above establishment is in good standing with the local E.H. Department? X YES _NO(explain below): <br /> Out of County RENS: Kc�c�ernn^Q L`^�� I es 1 3�� 1 a 1 - 3- 2 DL, 3 <br /> Print Name Signature Date <br /> I certify that,to the best of my knowledge,the above information is true and that I will comply with all applicable local,city, <br /> county,and state requirements. <br /> "`1 o90 /-d 3 Z?i <br /> Vehicle/Business Operator: Prim Na e Signature Date <br />