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IWU1 <br />Environmental Health Department <br />Date(s): I.Name of Event: 1. <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />TEMP EVENTAPP <br />Approved water for drinking, utensil and hand washing will be provided In my booth by the following methods: <br />O Approved bottled water. <br />7. <br />8. <br />SANJOAQUIN <br />-----COUNTY----- <br />CrcotncM groivi here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />AH 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 />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenue | Stockton, California 952051 T 209 468-34201 F 209 464-0138 | www.sjcehd.com <br />EHD 18-02 P»S« T of 11 T"‘" <br />07/3/17 <br />Z (/) stfa <br /> Alternate: <br />------ ------------ <br /> On-site hose bib that Is connected to^a potablp water s^prce. zh <br />JZ) Olher(specify): bU <br />Electricity is provided for my booth's use: Yes 0 No' <br />I am providing an accurate probe thermometer to measureJha hot andxpld halcMg of potentially hazardous <br />foods during all times of booth operation: Em Yes No J- r <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135T: . <br /> Camp stove Stemo & hotel trays . / <br /> Double steamer Steam table & lids . 0/ / >1//1 <br />Q Electric stove top (ifoiher (specify) /(/ ffl \a/( ^7 / <br />meats, tamales, cooked beans, rice, <br />The following is information about my organlzation/buslness: <br />Name of organlzation/buslness: M tX Hi ^70 <br />Address: Dm Utfb, yiz. z^A?; <br />List food to be sold or given to the public: <br />I am providing food that Is NOT prepared at home: |t^ Yes □ No \ <br />All food Is prepared qn-slte or is from approved commercial facilities: Yes No { OO (J ttohw <br />Name of facility. r^lAyh-HlW Phone:/ <br />Address of facility ) Y <>6^ /.$JU<cU0t <br />I am providing a booth with the following: (to protect my unpackaged food and food-prepflfation 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 cleanabla 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 />[Vf other (specify): / got-/ Z f A fi <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.