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Environmental! Health Department <br />.'•> i <br />Date(s): 1. Name of Event:1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />7. <br />8. <br /> Other (specify):_ <br />Note: The only operations not required to provide enclosed booths <br />: " "" <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 />foods during all times of booth operation <br />I am | <br />135°F: <br /> Camp stove <br /> Double steamer <br /> Electric stove lop <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sicehd com <br />DtartA 7 rtf 1 1 * CMi tVCrf IEHD 16-02 Puga 7 or 11 <br />07/3/17 <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 />Fame HkV <br /> Other (specify): _________________—,------------------------------------------------------------------------------------ <br />Electricity is provided for my booth's use: YesXJ No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />fua uui iny an umcj w.'wooth operation: 0 Yes No <br />providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Sterno & hotel trays <br /> Steam table & lids . <br />[Zf Other (specify) XUSuldW RxCC <br />meats, tamales, cooked beans, rice, <br />SAN JOAQUIN <br />------COUNTY------- <br />' G/culness yrcnvi Ik’i-. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />The following is information about my organizalion/business: <br />Name of organization/business: L>OCC> -------------------------------------- <br />ibiz. U. LoA'i A<c ___________ <br />Alternate: (qi\2) <br />List food to be sold or given to the public: VoVlC j ZlCcL y— <br />I am providing food that is NOT prepared at home:^fYes Q No <br />All food is prepared on-site or is from approved commercial facilities: [ZTYes No <br />Name of facility: v Iffine: lQ>\-------- <br />Address of facility: \ CA ---------------------7------------( — <br />I am providing a booth with the following: (to protect my unpackaged food and food-pieparation aieas 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.