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SAN JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility* Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name The Brew Life Lic. Plate#4UJ2422 <br /> Owner/Operator Name Sue Quilici <br /> Business Mailing Address 19829 Alder Ave <br /> City Tracy State CA Zip 95304 Bus. Ph.209-346-6324 Alt. Ph. <br /> I,Sue Quilici , 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 penait' <br /> Signature Date <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name La Comisaria Modesto FA# <br /> Address 1211 S. 7th Street Bus. Phone 209-338-3663 <br /> City Modesto Zip 95351 Owner/Operator Cold Storage Commissary, Inc. <br /> Check all appropriate services provided: <br /> B Wastewater disposal N� 3-compartment sink IS( Electrical hook-ups <br /> la Solid waste disposal Er Food preparation Toilet and handwashing <br /> Q Hot& Cplfl water for cleaning ig Store refrigerated food IiZ Potable water <br /> Cil Store dry'food/supplies E2( Overnight parking CY Vehicle wash <br /> 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 / Date 3 /8/22 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />