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COMMISSARY/COMMERCIAL KITCHEN AGREEMENT <br />ALAMEDA COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH <br /> ! <br />Commissary / Commercial Kitchen <br />Row's Roll <br />Owner Name <br />Rowena Rono <br />Street Address <br />16201 S. Harlan Rd <br />City & Zip Code <br />Lathrop Ca 95330 <br />Cell Phone# Alternate Phone# <br />I, (Facility Owner/ Manager) Rowena Rono <br />agree to provide the following services <br />SERVICES PLEASE CIRCLE YES OR NO: <br />Facilities to prepare or package food <br />Toilet & handwashing facilities <br />Waste tank/sewage disposal <br />Garbage disposal <br />Potable (drinkable) water supply <br />Electrical hook-up <br />Equipment/utensil storage <br />Warewash facility (i.e. 3 compartment sink) <br />Any "NO" answers must be explained below. <br />to Row's Roll <br /> <br />AV 0 NO Dry food storage Ai CI NO <br /> <br />El tillA 0 NO Waste grease removal WO 0 NO <br /> <br />El (4 0 NO Chemical storage • of', CI NO <br />tts 0 NO Overnight parking (MFPU) I r:.1.-1, 171 NO <br /> <br />El0.1...1 CI NO Enclosed overnight parking (carts) L'11" M NO 4#10 <br /> <br />0 0.-1 CI NO Refrigeration/frozen food storage a -• iii NO <br /> <br />71 1;:i CI NO Supply food product — i.e. ice, meats L mrI71 NO <br />011'0 NO <br />Additional Commissary agreements may be required: <br />The printed name and signature of the facility owner/operator is required for the department to accept this <br />document <br />Print Authorized Signer Name Rowena Rono phone 4088702326 <br />Authorized Signer Signature ( Date 1/25/25 <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 commercial kitchen has a current health permit by signing below. The <br />establishment is in San Joaquin County/Lathrop County/City. <br />An REHS signatures verifies that the facility indicated in Section 1 meets CALCODE: Section 114294— 114297. <br />Ka,8-szo,c\c\-e_ L.\ c".( es 2_oc\ ko‘ b <br />Out of County RENS Name (Please Print) Phone . <br />/1 / 2-5 <br />Out of County RENS Signature & Date Received E-mail Address <br />7