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S A N J D A U U I N Environmental Health Department <br /> — -COUNTY <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> 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 coordirator three(3)weeks <br /> prior to this evert. <br /> 1. 1.Name of Event: Lot s T ee'L F�--tw <br /> 2. The following is information about my organization/business: <br /> Name of organQatlanlhusinass, �* S t kp Cb <br /> �"l l' ` - Q <br /> Address: 1�` )l V— �)f I\ L4 n M 1 � 1 cliff 1�1 u2.T <br /> Phone: ) 'J'Oi -1 1 Altemate:{ ) <br /> 3. List food to be sold or given to time public.� 2e4%VAtA,. OAH , <br /> 1 <br /> 4. 1 am providing food that is NOT prepared at home-❑Yes®No co t"*.O try. <br /> All food is prepared on-site or is from approved commercial fadibes:❑Yes�� � l. qNo�y <br /> Name of facility: - tLLhie -WS (AkWtlohone: "p`t 11I 7 <br /> Address of facility_ SIA Ynrtbuurn Le 1 C41 gg'2142 <br /> 5 t am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies. <br /> dust and the public) <br /> ❑A booth with walls and ceiling consuucted 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. i <br /> ®Other(specify): <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 /> 6. Approved water for drinking,utensil and hand washing will be provided in my booth by the following methods: <br /> ❑Approved bottled water. <br /> ❑an-site hose bib that is connected to a potable water source. y <br /> ©Other(specfy): �� � L� �T 0`� - yW 11 rfyltil�S h"A4 <br /> 7. Electricity is provided for my booth's use:❑Yes Pa No <br /> B. 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:4 Yes❑No <br /> 9. I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135* : <br /> ❑Camp stove ❑Stemo&hotel trays <br /> ❑Double steamer ❑Steam table&lids MAW <br /> ❑Electric stove tap [4 Other(specify) Y'ant!, MAW <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[ Stockton, California 95205 f T 209 468-3420[ F 209 464-0138 [ www,sicohd.com <br /> EU 16.OZ Pace 7 of 11 TEMP eYrNT ARP <br /> 117rVI7 <br /> I <br />