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12. <br />13. <br />Date <br />Health Permit <br />Soap tftpsnsw <br />Bleach- <br />.1 <br />I Cf^itsinert mt/si be <br />i <br />5 Gal Handwash <br />Wastewater Container <br />Garbage <br />Can <br />1866 E. <br />EHO 1&-02 <br />08/WW <br />- <br />53^3 <br />^Ice Cooler 1? <br />Cutting Board <br />Propane Stove . <br />_ Peper Hand Twnts <br />Environmental Health Department <br />Slamow-'Chsfft.TQ <br />- Dilh <br />Soap and Water <br />Piro ExlJnpujaher 1 <br />8«a'ftwr bucket-' <br />Wwch’a water For <br />elodOQ vMptng dothe <br />/—~T-------—- <br />Booth must be on <br />Concrete, Asphalt, <br />|L Plyvrood, or a Tarp. <br />Paoeaorfi09468'3420 I F 209 464-0138 | www.sjgov.org/ehd <br />TEMP EVENT APP <br />W; <br />/ <br />/ <br />- <br />SAN JOAQUIN <br />— county™ <br />’ 'Vts 5IJ? - (h r <br />0 ' *0* ■■ <br /> Ice chests Q Refrigerator <br /> Refrigerated truck ice bath and tubs <br />''Q Other (apecifr) M A_______ <br /> Tri^e comX^uPnk'9™ W,lh^b=ott' 'he sanlta^ cleaning of food preparstlon ut8n81| <br />Su^onFonn^^X'^b.eacC^onXX'19 Wtof a <br />□ ,owe'8) <br />lem^viding me following for adequate hand washing facillUas, but separate from utensil wash within myi <br />□ Water supply dispenser with warm water at a minimum of 100T (l.e. 5-20 gallon container wdh spigot) <br /> °ne separate tub (bucket or basin) for the collection of rinse/wastewater. ' <br /> Paper towels and pump-style aoap cnntairw <br />"TN ST ffaL°n5:° b6 " b°Dlh dUrinS a" h°Ure of ^^n: ; <br />14. Completed by:----- (PH lit____________ _ OWrUX" ^IldiU <br />__ Signature . <br />5-20 Ga! <br />HandweihWiler <br />I Hond 6 ind^ oir of irn) ground) <br />Hazelton Avenue J Stockton. California 95205 | <br />Proiw Tank <br />-----------------—4 <br />|UI <br />•y-- <br />M Si® <br />OF <br />ant <br />)W< <br />tiO, A;.; <br />US <br />tU <br />r^F^w mjlx . y7- <br />Rlnw Wuter Ble»ch and Wetor <br />/ Extra \ |C <br />Walar