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.W JUAULHN Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />Completed by:14. <br />Health Permit <br />Paper Hand Tcv.els <br />Soap dispenser <br />I Cutting Board <br />Bleach <br />Prupant I auk <br />Bleoch un<i Watvr <br />I ee Cxtirriuishut <br />Ice Cooler <br />Rinsa V.'ater <br />£*Xl/u Ik. faitf-t t I bod (.'intmif rj fHaSt be <br />UilMUli !. v.ciM o« "I I'M yound' <br />Stcmo w?Cha ff.ro <br />Dish <br />Garbage <br />Can <br />Booth must bo on <br />Concrete. Asphalt, <br />Plywood, or a Tarp. <br />□ Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />Z^One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />Q Paper towels and pump-style soap container. <br />Sanitizer b-c'x <br />bleach X water for <br />Storing wiping cloths <br />5-20 GJ. <br />Hand wash V/ator <br />’.Gul 111.<> I W...I. <br />W.ljtirW.ih I Ctintail.ei <br />Title <br />\X’ <br />L <br />z <br />Soap and Water <br />"’ Hh/Gllof! / vcmue j .Stockton, ( <br />LllU Sr^rj?. <br />Important** <br />Names of responsible persons to be present in booth during all hours of operation: <br />-------------------tb —— --------------------------------------------------------— <br />All food vendor booths are subject to inspection. Please make a copy of this application in <br />preparation for this event. A copy of this checklist must be in the booth at all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this event. , , <br />______ (Q; I 03 I <br />Signature 1 Title Date <br />Three deep tubs (basins 6-8 inches minimum), one for soapy waler, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of waler). <br />jSDetergent. bleach, and wiping cloths (cleaning towels). <br />LJ Tub to store wiping cloths in bleach solution. <br />am providing (ho following for adequate hand washing facilities, but separate from utensil wash v/ithin my <br />'' ani providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />□ Three compartment sink. <br />I am providing the following cold temperature control foi the cold holding of potentially hazardous foods below <br />45T (if food is used lhe following day, maintain below 4IT temperature): <br />0Jce chests [ J Refrigerator <br />□ Refrigerated truck Q Ice bath and tubs <br />IJ Other (specify) <br />• diforuiu 957U5 | I 209 468-34?0 | l‘ /t u k ; <br />P...U- R rrf 11 <br />P’uparw Stove