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Environmental Health Department <br />1. Name of Event: 1. <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />/ idiu Oft <br />7. <br />8. <br /> Stemo & hotel trays <br /> Steam table & lids <br /> Other (specify) <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 />__________ Alternate: ( 2^ ) <br />S i <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />Approved bottled water. <br />[jj^n-slte hose bib that is connected to a potable water source. <br />SANJOAOUIN <br />------COUNTY------ <br />G^eotncss crows here <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 coordinator three (3) weeks prior to this event. <br />Note: I <br />vegetables, potato salad, eggs, and dairy products. <br />■ r .. o. \.> V-. <br />fcoP'* <br /> Other (specify^__—-------------------------------- ------------------------------------------ <br />Electricity is provided for my booth’s use: Yes [J No . <br />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: Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />1?5°F: <br />0/Camp stove <br /> Double steamer <br /> Electric stove top <br />Examples of potentially hazardous food include: <br />Date(s): <br />The following is information about my organization/business: <br />Name of organization/business: <br />Address: Rd z __________ <br /> (2^ ) J'bk' <$/ S'? ___________ Alternate: ( 2^) <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home:’ZfYes □ No <br />All food is prepared on-site or is from approved commercial facilities: [j^Pes No <br />Name of facility: Phone: (^/^) 2^7^-------- <br />Address of facility: _ _ __ _— <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />[DfA 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 | F 209 464-0138 | www.ajgo^org/ehd^ <br />EHD 16-02 Page 7 of 11 <br />nAoa/onoi