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Environmental Health Department <br />4HV2613Lie. Plate#Business Name. <br />Eric and Jennifer Reis <br />453 Hearland Drive <br />209-815-2385 209-679-7500Alt. Ph. <br />95336 Own er/Ope rater <br /> Potable water <br /> Vehicle wash <br />ia}| notify the EHD immediately. <br />Date <br />Date REHS Signature. <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Commissary Name <br />486 Button AvenueAddress. <br />Manteca <br />Bus. Phone. <br />Pastor David Bliss <br /> Electrical hook-ups <br /> Toilet and handwashing <br />FA# <br />209-239-1371 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1. To be completed by APPLICANT <br />Sugar Lips LLC <br />2. To be completed by COJVIMISSARY OWNER/OPERATOR <br />Place of Refuge (Refuge Church) <br />Docusign Envelope ID: BF8C2627-155B-4ABC-B31E-DDA8B2AB3DD4 <br />SANJOAOUIN <br />------COUNTY------- <br />Greatness grows here. <br />^1 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />Q Overnight parking <br />, hereby state that the information I have provided is current, true and <br />Owner/Operator Name <br />Business Mailing Address <br />City Manteca Sta^Zip95337 Bus. Ph, <br />I Jennifer Reis , 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 />S i g n atu rd ______ <br />PAte.9/14/202 5 <br />City Manteca Zip. <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br />Q Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I David Bliss <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facW <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary owua*0sJaaJI notify the EHD immediately. <br />I t 9/15/2025 <br /> Signature -----------------------Date------------------------- <br />V A6594CFAD6D A413... ______________ ____________________ ________________________________ <br />3. To becompletedby theENVHEALTHjurisdictionoutside of San JoaquinCo^ <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.