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PUBLIC HVALTH SERVICES vpP�u` N..CpG <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION x <br /> Karen Furst, M.D., M.P.H., Health Officer c' P <br /> 4CIFORa <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> �l <br /> TEMPORARY EVENT APPLICATION <br /> (To be completed and signed by Event Coordinator,then returned to Environmental Health Division with all <br /> Food Vendors Checklists no later than two weeks prior to event) <br /> General Event File Information: LIc 01t V's i <br /> Luic <br /> 1. Name of Event: { 1 , i II <br /> 2. Datelfime/Duration of Event: 4 l� I 1 ` 7V r'� t' 7� S �4LII /Y� <br /> 3. Type of Event: 01695 01698 " Please see Notice to All Temporary Event Organizers"" <br /> 4. Location: I y r ;.Y ` X11' r] � ) ) • b i s ` f 1 J <br /> 5. Event Coordinator(name): 'A( / / ��1 � � � Telephone: r <br /> Mailing Address: I I J L'- 1 r l Civ <br /> 6. Number of food booths: ✓ non-profit: ` p/rofd:r <br /> 7. Approximate attendance: i/ i " J _'�_ Estimated average age: /`iCl u f Z )' <br /> Utilities: (please enclose a drawing or map of layout and utilities) <br /> 8. Is potable water supplied and available for each food vendor? OYes ONo <br /> 9. Is electricity supplied and available for each food vendor? i7Yes *0 <br /> 10. Method of disposal of liquid waste for food booths: r -�' �ti e i �" q '\L rf t <br /> 11. Number of toilets provided:_ I <br /> 12. Sanitary garbage disposal company(name): L '� '1 �� a I� c i Number of dumpslers: <br /> 13. Are janitorial facilities available? 1 V l <br /> Application: <br /> 14. Submit to: Environmental Health Division at least 2 weeks prior to the event: <br /> 1) Temporary Event Application 2) Application review fee - $87/hour (1 hour minimum) 3) Temporary Food <br /> Facility food vendors permit application and 4) Site plan <br /> 15. If Festival/Event is selected for inspection,the Event Coordinator will be billed for inspection time: ($87.00 per hour <br /> weekdays 8:00 a.m. to 5:00 p.m.; and for after 5:00 p.m. weekdays, weekends, and holidays the inspection is <br /> charged at the houdy rate, calculated at one and a half times.) <br /> 16. 1 understand that as a temporary event organizer, I am responsible for meeting State standards as described in the <br /> Division of En irons n/(al Hea/l�h policie n roc S. <br /> EventCoordinatoY ' <br /> ' signed date tj <br /> FoW.EH0007A <br /> A Division of San Joaquin County Health Care Services <br />