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Environmental Health Department <br />2 <br />AtfctnjMj <br />Chore <br />3, <br />4 <br />5. <br />6 <br />9. <br />n-a <br />moats, tsmaies. cooksd boans, ties. <br />7 <br />8. <br /><<••■■ Jillt JZZU—--------------------- ------ Aternnle ( 2OV ) <br />list food to bo sold or gh«n to tho puttc am. co*a tw * con, >■ & .»:<• water <br />llio ’olewny is. vifoniuilioc aboct my oryur.^aton.'bus.rcii <br />N«riw of orpani.MiorVbMtiir.eM ,u'^ Hoafr <br />412 QibetoWay $!»; 2 Moc^Mc- CA 95356 <br />K0“l'0r'AvCnU®' S,ocMon- Cohtofnlo 95205 | T 200 468-3420 | F 200 464-0138 | wvrw.sjwW com <br />0M/K tltfPEttNI AM- <br />I am piovidaig toed that to MOT peparsd nt home fej Yes Q No <br />All food » preparwi ao-»;1e of Is (far. apptwed ca«nmercial facilities Yes (“i No <br />NamedlaaBty -------------------------------------------------------------------p^e. i_____j___________ <br />Address v» factay___________ _ __________ ____ ' S^bk? *<h th°fO,0W,ft9; (,C pf0,cCi rny ^Psckased’focd □TCtoodproparatxin <br />Wnd £!,n® arid I ne nwh fly <br />scree., ng^ com pie te y enclosing open food areas. Il vnS also have a smooih and cteanab'e fkxy (concrete <br />trclr IhVpubk'^ ,K<:ep‘8,>te; W*, fo«J and food prepwMton <br />EJ ore r (fipeofy). endcagrt tra.ter_______________________ <br />Dete(s) | <br />Note: The «-ly operations not requred to prov-da enclosed booths me Ihose which sefc bovemaw from <br />Hppioved dcspensef*. or p>wpackag«<j food* fiCm apptoeed sowc«s <br />Approved vyettw lor drinking, vlensl nnd hm-d washing will be prozded K my booth by the fofowing methods: <br />Q Approved bottled water <br />0 On-«itfe hose bib that is connected to a potable water source. <br />H Other (specify) - -n ix-rfv.? fr<-s?i •wafer tar.j <br />Flectntity i» picnrifed <cx my licoth’s use |V) Y<r* 3 No ...... ..... <br />» em pros’ding an accurate prete thernr.iretar to measu't thfl t«rt and ccM ho'dro of potemiaKy h.va'd&us <br />foods cforino at tvnes of booth operaLon, 3 Yes O No <br />' P?v!d,!*8 f* foBowirg hot temperature control'for the fot hoMmg d all potcrtally hara-drm foorte above <br />1 jt> r \ <br />L) Camp stow stemo £ hotel trays <br />O Double steamer stoom table & Ids <br /> Etoclne sieve top Q other (specify) <br />Noto; Examples ot potentially hazardous food Include: <br />vegotabtes, potato salad, oggs, and dairy products. <br />SAN JOAQUIN <br />-----COUN I V <br />, (.ir-Ot TK Ii.'ii <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />*,e"’" • ** •“««**- w <«. to <br />1. 1.Name O' Evert t-iF.Trric-, M(yhc-t