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Date(s): <br />2 <br />co <br />I <br />[ <br />9. <br />[ ] Stem & hotel trays [ ] Steam table & lids <br />III Ity <br />‘ilH <br />4 I am providing food that is NOT prepared at home: <br />All food is prepared on-site or is from app <br />Name of facility: <br />Address of fecility: <br />1. y Name of Event: <br />2. The following is information about my or <br />Nameofor®nizaticm/business:__^e- ' <br />Address; l(>^ <br />Phone: ^0?Phone: 1'1-7 ~ Altenurtey <br />3. List food to be sold or given to the public; <br />[JNo <br />the hot and cold holding of potentially hazardous <br />res CiNb <br />for the hot holding of all potentially hamdous foods <br />KJYes <br />Moial fecilities: | <br />SAN JOAQUIN COUNTY <br />ENVIORMENTAL HEALTH DEPARTMENT <br />186S East Hazetaa Amtos, SteektoiL Califernia SSH» <br />Bnsfaws (M9)468^420 <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 <br />checkliw'to the festival coordinator three (3) weeks prior to this event. <br />y organization/busii^ss: s <br />: []No <br />MYes [JNo <br />Phone: 72$4- <br />Addressoffedlity: . .. <br />5. I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from <br />flies, dust and foe public) <br />WAbooth with walteaiMioeiliiJttt^^ <br />mebh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor <br />(concrete, asphalt, dean tarps and smooth wood are acceptable) and constructed to separate food and food <br />preparation areas from the public. <br />[' jOfoer (specif): ___________ ________„,,,....... ;......—------------------— <br />Note: Theodyoperatitmnotreqwredtopcovideenclosedboothsarethosewhichsellbevefagesfrom <br />approved dispensers, or prepackaged foods from approved sources. <br />6. Approved water for drinking, utensil and hand washing will be provided in my booth by foe following <br />methods: <br />W Approved bottled water. <br />On-site hose Wfoait is connected to a potable wato' scmce. <br />[ ] Other (specify): <br />7. Electricity is provided for my booth’s use: fd Yes <br />8. lam providing an accurate probe thermometer to measw <br />foods during all time of bpofo operation: <br />I am providing foe following hot temperature <br />above 135 degrees Fahrenheit: <br />MCamp Stove [^Double steamer [ ] Electric stove top <br />[ ] Sterna & hotel trays [ ] Steam table & lids [ ] Other (specify): ... , , r <br />Note: Examples of potentially hazardous food iiKlude: meats, tamales, C(M)ked beans, rice vegetables, <br />potato salad, eggs and dairy products.