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Environmental Health Department <br /> <br />10. <br />OR <br />12. <br />13. <br />14.Completed by: <br />Signature <br />I Pa^HaMTwnto <br />Sowdapanwr <br />BtoachProp** Stow <br />I <br />PrapewTa* <br />BtMtnMWttr <br />tee Cooler <br />TEWPEVENTAPPP»g« Serf 11 <br />0J <br />Health Permit <br />® Water supply dfeperwer with warm water at a minimum oflOOT (i.e. f^OgaSon containerwSh spigat). <br />^5 One separate tub (bucket or basin) for the cotedion of rtnse/wastewater. <br />Gtfbaoa <br />Can <br />EjSts <br />Vrt&W <br />6<MHend’MMh <br />^Paper towels and pumo-sMe sosb container. <br />Mamas of rasportsfcte parsons to be present in booth during aS hours of operation: <br />Store we»«ne <br />Cton <br />SwtKzsr bucfcM- <br />Msotfrtwarier <br />ssstagtriptogtWa: <br />I am providing the foltawing cold temperature control for the cold holding of potently hazardous foods below <br />45*F (if food Is used the fofcwing day, maintain below 41*F temperature): <br />CSlce chests □Refrigerator <br /> Refrigerated truck _□ Ice bath and tubs <br /> Other (specify) <br />SAN JOAQUIN <br />COUNTY <br />_z <br />1858 E. Hazelton Avenue I Stockton, Cafifomia 952051 T 209 488-34201 F 209 464-0138 | www.8jcehd.com <br />EKD1MJ2 P«0«ftaf11 <br />07/V17 <br />— . <br />Booth mu*U» on <br />Concrete, AsptwK. <br />Plywood, er a Tarp. <br />Oatfetf I____ <br />MO Grt. <br />Ma.WW.WMv <br />I am providing the Wfcwmg items within my booth for the sanitary cleaning of food preparation utensil <br /> Throe compartment sink. <br />Q Three deep tubs (basins 8-8 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 />S Detergent, bleach, and wiping cloths (cleaning towels). <br />Tub to store wiping cloths In bleach solution. <br />I am providing the foUcwing for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />All food vendor booths are subject to inspection. Ptease make a copy of tha appficatfon fa <br />preparation for this event A copy of this chackfist must be in the booth at an hours of <br />preparation and operation. Return original to fosttval coordinator thry weeks prior to <br /> TftfoT Date <br />(K3MftfiMMtardrn»0re«r <br />E <br />r i ____L^_____ <br />I S«p«rtWl*r I WmW»r | <br />JL- f FtaEahaSw'm