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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1. Name of Event: 1. <br />2. <br />1^ Z Phone: <br />List food to be sold or given to the public:3. <br />4. <br />5. <br />/Vp (t/d //j <br />6. <br /> Approved bottled water. <br />9. <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APP <br />7. <br />8. <br />SAN JOAQUIN <br />COUNTY----- <br />The following is infomration about my organization/business: <br />f / / 4^ <br />Pa <br />1868 E Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 18-02 Page 7 oi 11 TEMP EVEN! <br />07/3/17 <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br /> On-site hose bib that is connected to a potable water source. <br />Other (specify):O a I_____/ CC) <br />Electricity is provided for my booth'§( use: Yes GJ 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 CZf No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top Other (specify) <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 />I <br />I am providing food that is NOT prepared at home:^J Yes No <br />All food is prepared on-site or is from approved commercial facilities: 0 Yes No <br />Name of facility: c.> ^<2, .- ^ < < <;Phone: ( C\f.----- < <br />Address of facility:P C) /A <br />I am providing a booth with the following: (to protect my wnpackaged food and food-preparation areas from flies, <br />dust and the public) <br /> A 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 />Gj Other (specify): i z c Pi/ <br />u 7 <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 />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />Date(s): Z./-0 m <br />Alternate: ( <br />d <br />Name of organization/business: <br />Address: _____