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All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival coordinator th ee (3) weeks prior to this event e) <br />t4 Sdij ft6Otbdi NICISttitS Date(s):9 /41 <br />The following is information about my organization/business: 0 )1)11,i, <br />Name of organization/busines 21 Icti1K-16 n 1-104.5 <br />Address: 14--tt4 10 CC? <br />Phone: q;‘)N Q)3(0 5-4TD Alternate: ( ) - <br />00v. rvibuif 4191S, Vla Chdc12-4) <br />List food to be sold or given to the public: it_qc/ ,v 0p e a cif 1 vyks ) <br />I am providing food that is NOT prepared at home: es El No <br />All food is prepared on-site or is from approved commercial facilities es D No <br />Name of facility: _ Phone: (1)9) <br />Address of facility: 1 '7 ti 1,0, if) ,A Cc, 9 316, <br />I am providing a booth with the following: (to protect my unpackaged food arid food-preparation areas from flies, <br />dust and the public) <br />CI A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />....-CiOther (specify): a. 0--• <br />Note: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />..1-,./!1/4,pproved bottled water. <br />El On-site hose bib that is ponnected to a potable water source. <br />.1.1c.:)ther (specify): 3 t ttg b ui 421:i <br />Electricity is provided for my booth's use: El Yes fl No Li <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: I] Yes El No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />D Camp stove 111Sterno & hotel trays <br />LI Double steamer JRSteam table & lids <br />El Electric stove top El Other (specify) <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />06/29/2023 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY— <br />Greatnss qrow fl7 <br />TEMPORARY FOOD VENDOR'S APPLICATION <br />1. 1. Name of Event: