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Environmental Health Department <br />( <br />1. Name of Event:1. <br />2. <br />Address: <br />) Alternate: (Phone: <br />ooo)^^3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />( <br />7. <br />8. <br /> Other (specify): <br />Note: The only operations not required to provide enclosed booths <br /> Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <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 />L-odi fam's A/l^W <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 />1868 E. Hazelton Avenue | Stockton. California 962051 T 209 468-3420 | F 209 464-0138 | www.sJceM.com <br />EHD 16-02 Pago 7 of 11 <br />07/3/17 <br />SAN JOAQUIN <br />------COUNTY------- <br />Gicoliii’ss t/ior.'s lit.’ii . <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />( J... <br /> Other (specify):------------------------------ ---------- --------------------------------------------------------------------------------- <br />rx^di^ “id hoidi^ °f p°,an,iaiiy hazardous <br />foods during all times of booth operation: 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 /> Camp stove Sterno & hotel trays <br />0 Double steamer Q Steam table & lids <br />Q Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />natais): <br />The following Is Information about my organization/buslness: <br />Name of organization/buslness: <br /><^g7 <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home: □ YesJ/f No <br />All food is prepared on-site oris from approved commercial facilities: JZfYes No <br />Name of facility: W* _Phone: (^9) --------------- <br />Address of facility: ^7 9^^ M- ------------ ------------—— <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation aieas from flies, <br />dust and the public) <br />D 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.