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Environmental Health Department <br />TEMPORARY FOOD VENDOR'S APPLICATION <br />1. <br />2. <br />Phone: <br />/3. <br />4. <br />5. <br />-r^re^ <br />6. <br />9. <br />/lo <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />SAN JOAQUIN <br />COUN ' Y ■ -• <br />Date's): ^((-17 / <br />Cs-f/ee s c c/ <br />■""> As <br />Name of facility: /C/'-h' <br />Address of facility: Hr 13 h A T <br />I am providing a booth with the following: (to protect my unpackaged food and food-preoaration areas from flies, <br />dust and the public) <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 />S Other (specify): AV-fe. /j M 7-^775 7/Xj / <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 /> Approved bottled water. <br />All food vendors (both for profit and non-profit) <br />the festival coordinator three (3) weeks prior to this event. <br />I.Name of Event: Lodi J <br />X^HaZel,OnAVenUe| Stockton. California 952051 T 209 468-34201 F 209 464-0136 | WOTr.sjgov.oro/ehd <br />ee/ig/tg !-2ge7oftl TEMo EVENT APP <br /> On-site hose bib that is connected to a potable water source. <br />S Other (specify): ^y'b/>h 4^ S A /C / A f -i <br />Electricity is provided for my booth's use: Q Yes No * ---------------------------------1 fffisixxRarthe hot and Mid howin3 °'poten,iaiiy hazardous <br />1 a,™ Pr°vidin9 fe following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Camp stove Stemo & hotel trays /io /AH" Aoec/Zs <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. <br />./7 JA-5 y-zj'Z <br />are required to return a signed and completed copy of this checklist to <br />The following Is Information about my organization/business: <br />Name of organization/business: 7S6 Z y^j <br />Address: /0^0 J} f'y S <br />? } '752.-Alternate: ( ) <br />List food to be sold or given to the public: Z z'Zcy tT c/ 47-^ <br />I ajri providing food that is NOT prepared at home: 0 Yes No <br />ZMI food is prepared on-site or is from approved commercial facilities: S Yes No <br />Name of facility: Phone: J£?~,2“77/