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SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> Greotness grows here. <br /> COMMISSARY-AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1 . To be Com leted by APPLICANT <br /> Business Name Row's Roll Lic. Plate#4A32978 <br /> Owner/Operator Name Rowena Rano <br /> Business Mailing Address 405 Eastwood Ave Apt#401 <br /> City Manteca State CA Zip 95336 Bus. Ph.408-807-2326 Alt. Ph. <br /> I Rowena Rono hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County,Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date ll' y zo <br /> 2. To be com ' leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La Comisaria Modesto FA# <br /> Address 1211 S. 7th St. Bus. Phone 209-338-3663 <br /> City Modesto Zip 95351 Owner/Operator Cold Storage Commissary Inc. <br /> Check all appropriate services provided: <br /> ® Wastewater disposal ® 3-compartment sink 13 Electrical hook-ups <br /> ® Solid waste disposal ® Food preparation 13 Toilet and handwashing <br /> El Hot &Cold water for cleaning ® Store refrigerated food ® Potable water <br /> 61 Store dry food/supplies ® Overnight parking 13 Vehicle wash <br /> I Mark Luis-Cruz , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature <br /> 3. To be com le the ENV HEALTH jurisdiction outside o an Joa uin Co. <br /> The commissa orated in County. The above food ility meets the <br /> commissary r irements in California Health & Safety Code. The above checked services are a ailable at the <br /> above com issary. Please notify EHD if the status of their operating permit changes. <br /> REHS S nature Date <br /> 1868 E. azelton Avenue I Stockton, California 952051 T 209 468-3420 464-0138 I www.sjgov.orglehd <br /> fir- <br />