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Environmental Health Department <br />Date(s);_4/-5 '.,25 <br />2 <br />Phone <br />3. <br />4. <br />5 <br />6 <br />9 <br />meats, tamales, cooked beans, rice, <br />7. <br />8 <br />SAN JOAQUIN <br />SHaZe"0nAVOnUe| StoCk'°"-Califom'a 9S20£[7U09468 ^ I r 20*464.0138 , wwws^g/el^ <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />10 8 ** ™ 0' -s checks. t0 <br />1 1 Name of Event: I <br />The following is information about my organization/business: <br />Name of organization/business: ^7^C.q d <br />Address: <br />-----------------------Alternate: ( ) <br />List food to be sold or given to the public: rZZg,o^j5u r a, Lg Que,^, ’ <br />I am providing food that is NOT prepared at home: EfYes No <br />All food is prepared on-site or is from approved commercial facilities. FfYes No <br />Name of facility: Phone’ Address of facility: ____________ ------- <br />1 dust an?the puS)h 'b® f°"0Win9: (t° Pr0,eC'my “"^^aed food areas from flies, <br />tSS—SESS <br /> Other (specify); <br />Nole: ~ d“ <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods. <br />IkfApproved bottled water <br /> On-site hose bib that is connected to a potable water source. <br /> Other (specify): / <br />Electricity is provided formy booth's use [±fYes[ ^o ------- -------------- ~ ------------ - <br />1 fomo^ h°‘ -d cold bowing of potently hazardous <br />lam^rovidmg the following hot temperature control for the hot holding of all potentially hazardous foods above <br />r^Camp stove sterno & hote| frays <br />[^Double steamer Q steam table & lids <br /> Electric stove top Q other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products.