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SAN,JOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY— <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 completed by APPLICANT <br />Business Name pineappleWHIIPS, LLC <br />Lic. Plate # 4RP3463 <br />Owner/Operator Name Jeffrey Taplin and/or Janeen Goedde-Taplin <br />Business Mailing Address4701 Fairfax Avenue <br />City Oakland State CA zip 94601 Bus. Ph. (510) 640-2617 Alt. Ph. <br />I, Janeen Goedde-Taplin , hereby state that the above information is current, true and correct <br />to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health <br />& Safety Caand San Joaquin County Environmental Health Department (EHD) requirements. If the use of <br />the commi(sary discontinued ' .,ermit holder must notify the EHD. Failure to notify this office may result in <br />permit revoc.ationknd penalties/1/19/2024 <br />Signature Date <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name E 14th Eatery + Kitchen FA# <br />Address 16395 E 14th Street <br />Bus. Phone <br />San Leandro 94578 Mandela Partners City Zip Owner/Operator <br />Check all appropriate services provided: <br />x Wastewater disposal <br /> <br />O 3-compartment sink <br /> <br />Electrical hook-ups <br />121 Solid waste disposal <br /> <br />O Food preparation Toilet and handwashing <br />0 Hot & Cold water for cleaning O Store refrigerated food <br /> <br />?.ci Potable water <br />CIStore dry food/supplies O Overnight parking Vehicle wash <br />1, Loren Johnson , 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 he EHD immediately. <br />Signature 1-alrell" Date 1.19.24 <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in /1 G1144-dt1 County. The above food facility meets the <br />commissary requirements n 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 /> <br />Date ( 2•67 <br /> <br />2-0 REHS Signature <br /> <br />1868 E. Hazelton (venue I Stocktdn, California 95205 T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />PRO5L11-ig