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Environmental Health Department <br />1.I.Name of Event: <br />2.The following is information about my organization/business: <br />KC Kombucha SacramentoName of organization/business: <br />878 Lake Front Drive, Sacramento, CA 95831Address: <br />( 916 ) 201-0725 ) Alternate: (Phone: <br />List food to be sold or given to the public: non-alcoholic kombucha3. <br />4. <br />5. <br /> Other (specify): <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods:6. <br /> Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />9. <br />7. <br />8. <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 /> Sterno & hotel trays <br /> Steam table & lids <br /> Other (specify) <br /> Other (specify): / ________________________________________________ <br />Electricity is provided for my booth's use: YestU No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />SAN JOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br /> 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: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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 />Lodi Pride <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 <br /> Double steamer <br /> Electric stove top <br />Date(s): 6/14/25 <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />07/01/2024 <br />meats, tamales, cooked beans, rice, <br />I am providing food that is NOT prepared at home: E5 Yes No <br />All food is prepared on-site or is from approved commercial facilities: Yes No <br />Name of facility: KC Kombucha Sacramento Phone: ( ) <br />Address of facility: 11353 Pyrites Suite 1, Gold River, CA 95670 <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)