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'oP urN eo SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> } 304 E Weber Avenue ani Floor Stockton,•CA 95202-2708 <br /> (209)468-3420•Fac(209)464-Q138•We6:www.cosau-juaquin•c&udehd <br /> �glrFOR�` TEMPORARY EVENT APPLICATION <br /> fro be completed and signed by Event Coordinator,then returned to Environmental Health Department with all <br /> Food Vendors Checklists no tater than tm weeks prior to event) <br /> GENERAL EVENT FILE INFORMATION / / L <br /> /i tan HecA 0DWnTwh CPe��rfi°a �aYr�� r1 �arJCe7 _ <br /> 1. Name of Event <br /> 2. Date of Event fp-7 ><d Y- 30-z0of Event q36-720 f lion of Event .Tune <br /> 3. Type of Event❑ 1695698 "'Please see Notice to A0 Temporary Event Organizers"" <br /> 4. Location: ec L;bray arK 4 CerifeY 4t ec 2. <br /> 5. Event Coordinator(Name): Ke- t-o o Telephone:(Lz"i 3- 7 2-2- 1 <br /> Mailing Address: P. o <br /> �. 6 0 A 10 SP yrrG+/!2 Fe cfl 609q5 3 3 <br /> 6. Number of Food Booths: 7/ Number of Food Handlers: ❑Profit Jon-Profd <br /> T Approximate attendance at peak Gree: 5 b O Total Attendance: a-crc>— Average (Af(ge`: 41-S <br /> UTILITIES <br /> 1. Is potable water supplied and available for each food vendor. Yes ❑No <br /> 2. Is electricity supplied and available for each food vendor: ❑Yes WNo <br /> _ 3. Are janitorial facilities available: `f' <br /> _ "es E]No <br /> 4. Number of toilets provided: � L ' <br /> 5. Name of sanitary garbage disposal company. i 1a11 kO lumber of dumpsters: 7' q6 ,�/a lr/o,f <br /> 6. Method of disposal of liquid waste for food booths: "/o f�S <br /> APPLICATION <br /> 1. Submit the following to Environmental Health Department two weeks prior to the event: <br /> a) Temporary Event Application <br /> b) Application Review Fee$93.00 hour with a 1 hour minimum <br /> c) Temporary Food Facility food vendors permit application <br /> d) Site Plan <br /> 2. If FestivalrEvent is selected for inspection,the Event Coordinator will be billed for inspection time: <br /> $93.00 per hour,weekdays 8:00 am to 5:00 pm. <br /> • After regular business hours,weekday,weekends and holidays,the inspection is charged at <br /> the hourly rate,calculated at one and a half times. <br /> This application is to be completed and signed by the Event Coordinator, then returned to Environmental Health <br /> Department with all food Vendoes Checklists no later than two weeks prior to event <br /> I understand that as a temporary event organizer, I am responsible for meeting State standards as <br /> described in the Department of Envir�onmmental Health ides and procedures. <br /> Event Coordinator. ��/�QiL� �/� �� Date: 5 /-Z 3� 5> <br /> rHo-rsozmz Page 1 of 9 TEWezwrisv <br /> enrzoo� <br />