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Commissar. Name: <br />City, State. Zip Code:Commissary Address: <br />Telephone: Commissary Owner's Name: <br /> Other: WarehouseS Restaurant MarketType of Facility: <br />YES <br />c <br />Out of County REHS: <br />Print wame <br />DaleSignature <br />[X] Refrig. / frozen food storage <br />[k] Supply /equipment storage <br />Electrical hook-up <br />M Garbage disposal <br />County. <br />NO (explain below): <br />I. the commissary' owner/operator. agree to provide the necessary facilities tor the above-mentioned vehicle at my <br />permitted facility as checked below: <br />Department of Resource Management <br />675 Texas Street, Stc. 5500 <br />Fairfield, CA • 94533 <br />www.sola nocou n ty.eom <br />Utensil washing <br />M Dry food storage <br />M Liquid waste disposal <br />[ ] Vehicle / carl storage <br />Environmental I lealth Division <br />(707) 784-6765 <br />E.H. DEPARTMENT AUTHORIZATION (REQUIRED) <br />The following information shall be completed by the local E.H. Department ifthe food establishment / commissary is <br />located outside Solano ( ountv: <br />File# <br />valid. A copy of the current health permit is provided. <br /> <br />Dale <br />COMMISSARY AGREEMENT <br />‘Completion of this Commissary Agreement is required prior to issuance of Solano County Permit of a Food Facility. * <br />^Si^6lure <br />[>4 Food preparation <br />[•4 Potable water supply <br />[ ] Food product supplier <br />[y] Restrooms <br />1 agree to notify Solano County Environmental Health of any change in the status of my operation or when this <br />commissary agreement is no Im <br />Commissary Owner/ Manager <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 slate requirements. <br />Vehicle / Business Operator: <br />Print Name <br />Vehicle Business Name: Piy <br />/lw rVle, <br />The food establishment / commissary is located in-----Sam -- <br />The above establishment is in good standing with the local E.H. Department? <br />3- <br />=- Date