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EnvironmentaS Health Department <br />1. <br />2. <br />Address: <br />3. <br />4. <br />Al/a- <br />/ <br />5. <br />6. <br />9. <br />meats-, tamales, cooked beans, rice, <br />/ <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8. <br />I am providing the following hot temperatun <br /> Sterno & hotel trays <br />I2[ Steam table & lids <br /> Other (specify) <br />All food vendors (both for profit and non-profit) afe required to return a signed and completed copy of this, checklist to <br /> Datefsj:^^ ObWVCY <br />1868 E-. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sicehd.com <br />EHD 16-02 Page 7 of 11 TEMP EVENTAPP <br />07/3/17 <br />Z^S/MAQUIN <br />V 1 COUNT Y <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />the festival, coordinator three (3) weeks prior to this-event. <br />1. Name of Event lo <m <br />The following is information about rhy organization/business: <br />Name of organization/business:. <br />Phone: Alternate: zpiq-i V7/) <br />List food to be sold or given to the public:. <br />I am providing food that is NOT prepared at home:<WYes EJ No <br />All food is prepared omsite or is from approved commercial facilities: [Vyes No <br />Name of facility: ,J i^/r Phone: /1 <br />Address of facility; _____ ■______________ <br />I ahi providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br /> A booth with walls and ceiling cohstfucted. of either wood, cafoVas, 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 />Qd 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 />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Approved bottled water. <br /> On-site hose bib that is. connected to a potable, water source. <br />fyf Othe/ (specify): ^7^^''IjIcLxS . / /Q/^LT'----------------------------------------------- <br />Electricity is provided for my booth's^us^^jYes No ‘ <br />t am providing an accurate probe thermorhetef-to measure the hot and cold holding pf potentially hazardous <br />foods during all times of booth operation: [Xj/Yds No <br />I am providing’the following hot temperature^ontrol for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top