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Environmental Health Department <br />10 <br />11 <br />OR <br />wiOim my12 <br />Water supply dispenser with warm water at a minimum of 100‘F (i e 5-20 gallon container with spigot) <br />3 One separate tub (bucket or basin) for the collection of nnse/wastewater <br />K Paper towels and pump-style soap container. <br />13 <br />••Important” <br />Completed by14 <br />Health Permit <br /><>>■(*• MM <br />I >9 I «tf V**’** <br />Ice Cooler (mI It* iJ -* J- <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utens.i <br /> Three compartment sink <br />yxi <br />K414 •<V‘ Awn <br />Cartage <br />Can <br />* »«■«» ta» <br />w-tx-x; >,naPW <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash <br />booth <br />1868 E Hazelton Avenue | Stockton California 95205 | T 209 468-3420 | F 209 464 0138 | www sjgov org/ehd <br />I nb I'ujc Wil HW'iW Ml APR <br />* < 'Wiei 71 <br />SAN JOAQUIN <br />t " (. ' l i N T V <br />| 11 .. .... ... <br />O U1»A P C <br />Title <br />I <br />W««» <br />r_Z <br />Booth musl be on <br />Concrete, Asphalt <br />Pfywocd or a To-'p <br />S! Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for nnsmg and one fo' a c <br />solution tone tablespoon of bleach per gallon of water) <br />S Detergent, bleach, and wiping cloths (cleaning towels) <br />® Tub to store wiping cloths in bleach solubon <br />Names of responsible persons to be present in booth dunng all hours of operation <br />v tll.rA ____________ ___ _________ <br />All food vendor booths are subject to inspection Please make a copy of this application m <br />preparabon for this event A copy of this checklist must be in the booth at all hours of <br />preparation and operation. Return original to festival coordinator thrf weeks prior to <br />this event <br />ti 11 <’v \<V F'' Oh) HP C _ Il r <br />f j Signature 0 Title Date <br />I am prcvd ng the following cold temperature control for the cold holding of potentially hazardous foods te o/* <br />45 F (if food is used the toiiowmg day maintain below 4 I F temperature) <br />$ Ice chests Refrigerator <br />O Refngerated truck [*} Ice bath and tubs <br />O Other (specify)—-----—