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EmvIroomenteB Health Department <br />2. <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice <br />7. <br />8. <br />SM JOAQUIN <br />COUNTY <br />are those which sell beverages from <br />eJo?«2 HaZeltOn Avsnue ' Stockton. California 85205 | 7,209 468-3420 1 F 209 464-0138 | ^-SJaov^eh^ <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />£&SK,^SXS==,“,--“ a signed and completed copy of this checklist to <br />1- l-NameofEv.nt.^g-HL^. /,^ Date(s);ZZ_-6 <br />The following Is information about my organlzation/business: <br />Name of organization/business:~7flf^ i <br />Address: -73V7 bpc <br /> Phone: Alternate:( <br />List food to ba sold or given to the public: <br />I am providing food that Is NOT prepared at home: E<s □ No ' <br />All food Is preparedon-slte or is from approved commercial facilities: B^es No <br />Nameo,Mily: <br />Address of fadllly^gy &/ -------------- <br />dust and the public? m th^oliow’ng: (to protect my unpTckaged food and food-preparation areas from flies. <br />asphalt, clean tarps and smooth S XSable) at rnn^La^00"’ al?d .c,eanable fl°°’ (Mncmte, <br />areas from the public. Ptabie) and constructed to separate food and food preparation <br />□ Other (specify): Tfg.lr.r ’=f^/^3t> <br />N°te: ^±aEeratlOnS nOt requ'red to Provlde enc!“ed booths <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 foitowlng methods: <br />E^pproved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br /> Other (specify):y <br />Electricity Is provided for my booth’s use: ETYes No ----------------------- ------ <br />foo*ttorin^^fl^^oXoperatoS:"S^nNoUreand ““ h°ldln9 °f poten“ally hazardous <br />^m providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />®^arnP stove S^temo & hotel trays <br />E'Double steamer steam table & lids <br /> Electric stove top other (specify) <br />Note: Examples of potentially hazardous food Include- <br />vegetables, potato salad, eggs, and dairy products. <br />. CA <br />).