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Docusign Envelope ID: ED22E9O8-7163-4143-A00D-17BA48EC399B <br />SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />LODI BEER FESTI.Name of Event:1. <br />2. <br />Rocklin, CA 95765 <br />Address: <br />Phono: <br />3. <br />4. <br />5. <br /> Other (specify): <br />6.Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Approved bottled water. <br />(xJ On-site hose bib that is connected to a potable water source. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />lx I 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 cleanable 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 />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 />The following is information about my organization/busincss: <br />smokin' Bliss Bbq <br />Name of organization/business: <br />3101 Strand Road. <br />Ix J Sterno & hotel trays <br />LI Steam table & lids <br /> Other (specify) Cambro <br />Alternate: ( ) <br />Ribs, chicken wings, pulled pork, sausage, water <br />List food to be sold or given to the public: <br />9168710686 <br />( ) <br />1868 I:. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />El to 16-02 Pago 7 of 11 TEMP EVEN 1 APP07/3/17 <br />All 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 />I Other (specify): <br />Electricity is provided for my booth's use: [ X Yes LI No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Fxl Yes [~] No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />LI Camp stove <br />U Double steamer <br />.1 Electric stove top <br />I am providing food that is NOT prepared at homo: (xl Yes [ ] No <br />All food is prepared on-site or is from approved commercial facilities: Yes I I No <br />Name of facility:Phone: ( ) <br />Address of facility: <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />-Dato(s):APRIL26.2025