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4r S A N J OA Q U I N Environmental Health Department COUNTY TEMPORARY FOOD VENDOR'S APPLICATION Ali food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to the festival coordinator three(3)weeks prior to this event. 1 1 Name of Event ` }~ �.ky u P Date(s) The following is information about my organizationlbusiness: Name of organization/busine55: Address k i") l Phone ( S10) C1-� '1_- �� - Alternate: ( C�d_ JS— �A j 3 List food to be sold or given to the public: ` n N e LS. Xk Cp-vt I N L -e�S{ r kt VV_at> 4 1 am providing food that is NOT prepared at home ' Yes ❑ No All food is prepared �on-site or is from approved commercial facilitiesxYes ❑ No ( Name of facility: 1_4 Phone { klti c�Z- } . Address of facility LAC- r c - 5. 1 am providing a booth with the following? (to protect my unpackaged food and food-preparation areas from flies dust and the public) ❑ A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor ;concrete. asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public ** � VOther(specify) _lam , �� c r�.� 14 `t't \,k-t Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers, or prepackaged foods from approved sources. 5 Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods U Approved bottled water. IxOn-sine hose bib that is connected to a potable water source []Other(specify) — 7 Electricity is provided for my booth's use. ❑ Yes TXNo E 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of booth operation %Yes [ ] No 9 f am providing the following hot temperature control for the hot holding of all potentially hazardous fcxads above 135"F ❑Camp stove ❑ Sterno 8 hotel trays ❑ Double steamer ❑ Steam table& lids ❑ Electric stove top Other(specify) 1'C'4 wlf Note: Examples of potentially hazardous food include: meats, tamales, cooked Deans, rice, vegetables, potato salad, eggs,and dairy products. 1868 E Hazelton Avenue 1 Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www s)gov,orglehd Elio l6-J2 PWjW 7 CA11 1kMP EVENT App U7n]lrerx4