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Environmental Health Department <br />(Ms <br />11. <br />OR <br />12. <br />13. <br />14.Completed by: <br />Signature <br />Health Permit <br />Paper Hand Towels <br />Soap dispenser <br />Cutting Board <br />BleachPropane Stove <br />Bleach and Waler <br />Fire Extinguisher <br />TEMP EVENT APP <br />B <br />. r-.I <br />Soap and Waler <br />Extra Ice Bags & Food Containers must be <br />stored 6 inches off of the ground! <br />Stemo w/Chaffing <br />Dish <br />ik^> /U <br />Extra <br />Water <br />5 Gal Hand wash <br />Wastewater Container <br />Garbage <br />Can <br />Sanitizer bucket­ <br />bleach & water for <br />storing wiping cloths <br /> Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />5-20 Gal. <br />Hand wash Water <br />|f responsible persons to be present in booth during all hours of operation: <br />Z - I f/'2) - <br />Ice Cooler 1 <br />___ __F <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 —/ Z7 / <br /> <br />Title <br />Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />I <br />Q^One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />Paper towels and pump-style soap container. <br />Propono Tank <br />lapn providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />H Three compartment sink. <br />Rinse Water <br />** Im porta nt** <br />7-/A ZdZ-5 <br />Date <br />Name§of responsible persons to be pre:Pns+h - <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />Ej Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />0iDetergent, bleach, and wiping cloths (cleaning towels). <br />E^Tub to store wiping cloths in bleach solution. <br />> r-y-r <br />10. <br />SANJOAQUIN <br />------COUNTY------ <br />Greotness ^rows here. <br />I am°providing the following cold temperature control for the cold holding of potentially hazardous foods.below <br />45°F (if food is used the following day, maintain below 41°F temperature): <br />[vi Ice chests Refrigerator <br /> Refrigerated truck Ice bath and tubs , <br /> Other (specify) <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />_ . "rr~^ m r“» /f“MT a l <br />EHD 16-02 Page 8 of 11 ....... <br />oc/oo/oaop