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SAN JOAQUIN Environmental Health Department <br />TEMPORARY EVENT APPLICATION <br />To be completed and signed by Event Coordinator, then returned to the Environmental Health Department with all <br />of the Food Vendor's Applications no later than two weeks prior to event <br />GENERAL EVENT FILE INFORMATION <br />Name of Event: L;w# <br />Date(s) of Event: 0123123 - 07131123 Time of Event: <br />Location: 7tTatoot, Lotlk-ee 1>r;02. LA.irirvirop 415330 <br />Event Coordinator (Name): '&rr cio. COtkin. Telephone: (55q) siti 51 as <br />Mailing Address: 11113 she% "Wive LAHigetc , CA. 1533o <br />Number of Food Booths: <br />Approximate attendance a ak time. 2-00 Total Attendance: Average Age: 5 <br />UTILITIES \)e0:000- <br /> Is potable water supplied and available fur each loud vendor. E'Yes fl No <br /> Is electricity supplied and available for each food vendor: g"Yes El No <br /> Are janitorial facilities available: [21/Yes El No <br /> Number of toilets provided: <br /> Name of sanitary garbage disposal company: Number of dumpsters: <br /> Method of disposal of liquid waste for food booths: <br />APPLICATION <br /> <br />1. Submit the following to the Environmental Health Department two weeks prior to the event: <br />Temporary Event Application <br />Application Review Fee of $152 <br />Temporary Food Vendors Applications for each booth <br />Temporary Event Site Plan <br />Food Vendor List <br /> <br />2. If the event is selected for inspection, the Event Coordinator will be billed for inspection time: <br />$152 per hour (weekdaya 8:00 am to 5:00 pm) <br />After regular business hours (weekday. weekends and holidays) the inspection is charged at the <br />hourly rate, calculated at one and one half times ($228 per hour) <br />This application Is to be completed and signed by the Event Coordinator, then returned to the <br />Environmental Health Department with all Food Vendor's Applications no later than two weeks prior to the <br />event. <br />I understand that as a temporary event coordinator, I am responsible for meeting California State <br />standards and the Environmental Health Department policies and procedures. <br />Event Coordinator: <br /> <br />Date: 0 b4113 <br /> <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I wvvw.sicehd.com <br />51-1D 16-02 Page 1 of 11 TEMP EVENT APP <br />07/3/17