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Environmental Health Department <br />1. <br />2. <br />Phone: <br />3. <br />4. <br />6. <br />6. <br />9. <br />J <br />7. <br />8. <br />18B8E Hazelion Avenue I Stockton, California S62061 T 209 468-3420 I F 209 464-0138 | www.ajcehd.oom <br />EHD 16-02 Page 7 Oi 11 <br />07/3/17 <br /> 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 /> Other (specify): _ <br />Electricity Is provided for <br />foods during all times of booth operation: Yes No <br />I am | _................. <br />135T: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />Note: Examples of potentially hazardous food Include: <br />.Z’PVSANJOAOUIN <br />h ' -----COUNTY------ <br />Grcdlncss ijrows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />I am providing an accura^^rabe Ihenaomelar ^Leasure lhe hot and cold holding of potentially hazardous <br />proving hot holding of all potentially hazardous foods above <br /> Sterno & hotel trays <br /> Steam table & lids j <br />pother (specify) <br />' • ‘ ichide: meats, tamales, cooked beans, rice, <br />vegetables, potato salad^eggs, and dairy products. <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />lhe festival coordinator three (3) weeks prior to this event. , i <br /> <br />Warne of Event: ' 5 IAX __________Datafe): J / G> / Z3 <br />The following is Information about my organlzation/buslness: - > \ i C <br />Name of organlzation/buslness:s. <br />Address: frOWL <br /> Alternate^ ) -----------------------s— •pO <br />List food to be sold or given to the public: co\cY pressed <br />I am providing food that Is NOT prepared at home: Yes LZNo X C < 5 <br />All food Is prepared on-site or Is from approYpdcommerclal facilities: J^YesfflNo^^x "7 “ UjS' <br /> c agio'T <br />I am providing a booth with Vie following: (to pfStecl my unpackaged food and food-preparation areas from files, <br />dust and the public) <br /> A booth with walls and celling 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 lhe public.