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SAN JOAQUIN Environmental Health Department l, 0 t,J ICI T Y TEMPORARY FOOD VENDOR'S APPLICATION All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to the festival coordinator three(3)weeks prior to this event- 1- 1.Name of Event: �' �� `- ~ ❑ate(s):'?�C:L I 2. The following is information about m organization/business: rr Name of organ ization/twsiness: !J'rr C: k Address: � ��J�t- � �(-� I-�'J G-- � r � l't•- 5� r� � Phone: Aftemate: (7 rl"3' 3L 3- List food to be sold or given to the public: { i�F - oC,_o ke, l',e '! 4- l am providing food that is NOT prepared at home:12 Yes❑ No All food is prepared a e or is from approved commercial facilitie:�Yes❑No Marne of facility: �.{ J > s Phone: ('C� Address of facitty: /- l r 5. I am providing a booth with the following: (to protect my packaged food and food-preparation areas from flies, dust and the public) ❑ A booth with walls and ceiling constructed of either wood. canvas, plastic, similar material and fine mesh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public, Other(specify): `f r' r` - ct •. s Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers, or prepackaged foods from approved sources. 6- Approved water for drinking,utensil and hand washing will be provided in my booth by the following methods: []Approved bottled water. ❑On-site hose bib that is connected to a potable water source. ❑Other(specify): 7. Electricity is provided for my booth's use: ❑Yes ErNo 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of booth operation: ❑Yes DNo 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 135'F: ❑Camp stove ❑ Sterno&hotel trays ❑ Double steamer ❑ Steam table&lids ❑Electric stove top ❑ Other(specify) Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, vegetables, potato salad,eggs, and dairy products. 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 46a-3420 I F 209 464-0138 f www.sjcehd.com EH❑1c-02 Pagr-7 of 1' TEMP EVENT APP o7+v+7