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5 <br />Date(s):/?(/4 -1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />the hot and cold holding of potentially hazardous <br />9. <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8. <br />[^Approved bottled water. <br />t^On-site hose bib that is connected to a potable water source. <br /> Other (specify):__ ____ <br />Note: The only operations not required to provide enclosed booths <br />SANsJOAQUIN Environmental Health Department <br />-,c.ouTr- <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />(2^ ) <br />List food to be sold or given to the public: <br />The following is information about my organization/business: <br />Name of organization/business:.A/4?tSkh/ —W <br />//.33S P£WKt>U Uh. . CA ^21/0_______________ <br />8757 Alternate: ( ) 3 2 7 37?------ <br />; 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 />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 three (3) weeks prior to this event. <br />1. Name of Event: %A//<^ /7/ MflR ~T <br /> Other (specify):_____________ <br />Electricity is provided for my booth’s use: 0 Yes No <br />I am providing an accurate probe thermometer to measure <br />foods during all times of booth operation: 0 Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />0 Camp stove [j^Stemo & hotel trays <br /> Double steamer O Steam table & lids <br /> Electric stove top D Other (specify) <br />Note: Examples of potentially hazardous food include:meats, tamales, cooked beans, rice, <br />I am providing food that is NOT prepared at home: Yes No <br />All food is prepared on-site or is from approved commercial facilities: Yes No <br />Name of facility: S7^ Phone: —V 7 —^ 2— ----- <br />Address of facility: %00 fl kJs^FJ-f) t ^~TC>C/K~Ltr^L QflL------ ------------------------------------— <br />I am providing a booth with tne following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />[0A 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 />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgovWehd^ <br />EHD 16-02 Page 7 of 11