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SAN OAQUi ! Fnviranmental health Department TEMPORARY FOOD VENDOR'S APPLICATION All food vendors f botri for profit and ion-profit)are required to retjrn a signed and completed copy of this checklist to the festival coordinator three 1,3)weeks prior to this event 1_ 1 Name of Event. - _�rfrz��/ -, rL _ Date:s), $" 2. The following is information about my organizationlbusiress� Name of organ izationlbusiness _ -:S-o,- 1,_"ZKZZ Qi V --- Adc ress: 7S� S - I// !'�/ - �� t ��•s ( t�/�.7 x-Z Phone. 3. List food to be sold or gnen to the public: 4. 1 am providing food that is NOT prepared at home:['Yes No ✓ All food is prepared on-s'te or is fro+n approved commercial)facilities. ❑Yes KNo Name of facility. Phone.{ Address of facility: 5. 1 am providing a booth with the i o+ning- (to protect my unpackaged food and food-preparation areas from flies, dust and the public) ❑A booth with walls and ceiling constructed of tither wood,canvas plastic, similar material and fine mesh flit screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth mood are acceptable)and constructed to separate food and food preparation areas from the public. (J Other(specify) Note: The orly operations not required to prDvAe enclosed booths are those which sell beverages from approved cispensers,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, �f / On-site hose bib,hat is connected to a potable water source. Other(specify): — 7. Electricity is provided far my booth's use, ❑Yes X No 8. t am providing an accurate probe thermometer easure t fhiot nil cold holding of potentially hazardous foods during all times of booth opteraon:;1 Yes U No S. I am providing the folloriing hot temperature control for the hot h1irdirlg of all potentially hazard,us foods above 1 35"F: U camp stove ❑Starno&hotel trays ❑Double steamer ❑Steam table&lids /r Elec`.ric stove top ❑Other'specify) �[, Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, r}ce, vegetables, potato salad,eggs, and dairy products, 1863 E.Ma_elton Avenue I Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138 1 vnvVJ.sjcehd.�orn 7E?a E' 'E!.f Ail ti fi.r.