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■sAN JOAQUIN Environmental Health Department <br />utensil wash within my <br />nportant** <br />Completed by: <br />I <br />| Soap ^sponsor | <br />QI <br />4 <br />e Cooler <br />0 <br />Exva <br />Waler <br />Garbage <br />Can <br />San-W er bucket- <br />bl c act' A waler lor <br />stonr'g wiping doini <br />Booth must be on <br />Concrete. Asphalt. <br />Plywood, or a Tarp. <br />Slerno wASnanmg <br />Os" <br />S-?0 Gal <br />Hand wosh Water <br />Health Permit | <br />? d5T (if food is used the following dXmaintaTbXw^iT te°m jb01?09)°f P°tenIial,y hazardous foodS bel°W <br />[J Ice chests q Refrigerator <br /> Refrigerated truck Ice bath and tubs W/ <br /> Other (specify)— 7 f' <br />Paper Hand rowcu | <br />Eifca te O»9J A Food Conlimett muil ftc <br />stored 6 ncAea di ot tht ground1 <br />J Soap and Water j J Rm»o Water <br />fira r Xtinguilhor <br />1 f l,'0,Ch w,lc' <br />' .izollon Avenue f <br />160? <br />20?d <br />Slockton CaMornia 9520S | T 209 ^8-3-1201 f 200 464-0133 | Wm 5|qov orgOJ-.d <br />8 0,11 TEMPCVt NT APP <br />S Gal Hand waih <br />Wastewaler Conl3<ncr <br />XI Water supply dispenser with warm water at a minimum of 100’F (i.e. 5-20 gallon cont <br />X3 One separate tub (bucket or basin) (or the collection of rinse/wastewater. <br />XJ Paper towels and pump-style soap container. <br />Names of responsible persons to be present in booth during all hours of operat’ <br />__________________________________________________________________________________________________________________________________________________________________ __________________________________ ________________________________—"■ ‘ <br /> All food vendor b^ihiTre subject10 booth at all hours of <br /> iEASSS—»««««« <br /> ---------- ----------------------------- - Tit in Date Signature----------111,0 <br />Li'C: compXttTnl',emS Wilhin my b0°,h ,Or ,te sanilarv cleani"9 ,0°d prepa'3li°n UtenS" <br />^//) <br />[J Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a b <br />solution (one tablespoon of bleach per gallon of water). <br />Detergent, bleach, and wiping cloths (cleaning towels). <br />■U Tub to store wiping cloths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but separate from <br />booth: <br />inane Store