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Environmental Health Department. J <br />i. <br />2. <br />Pheno <br />3. <br />4 <br />6 <br /> Othe' (specify)’ <br />6. <br />6. <br />rnoala, lamnlea, cooked h*ans, rlc*. <br />1666 E HazeHwi Avenue | Stockton, Caltania 95205 ^ 408-3420 | F 209 434-01M | wMv.sjceM.com <br />7. <br />8. <br />SAN JOAQUIN <br />------COUNTY <br />ick .p,,, , <br />TEMPORARY FOOD VENDOR'S APPLICATION <br />Ax^roved w««tea foi chkiki"^. ulent I and band Aashc-g will be p'owJed n niy booth by Ir-e ioltoatng owthcci. <br />p^ApfxanJd bottled wale/ <br /> On-« »e Ikoie b» that H connected Io o potobio waler fiGurce. <br />uerow AXp-tt lU.VL.LLl<AAS41L^.‘.J__________________ <br />( / A l~ _ Akemaie (^L'l ) Zt-?' I__Zd-_ <br />List toed to be sob cr gpver. to the public 1 Cftti “> o <br />I am prov.ding food that ts HOT prepped horre No <br />Steam table & lids <br />Otb^ (specify) CIH* I ■ *' r <br />Noto: Tito only cco/alicns no! /ecjui/ed to provide enclosed booths a/e iiio»e wh:ch set towopos from <br />approved dtspenwra, or ptopeckdped foods frcri approved scurses <br />AB food t»pfeoaiod on-site oris fretn approvedcowto'oaitedMtot ij,’ Yes O No <br />Name of facilty, n. li'* f^tone ( | <br />Address of fac«y.vACT ...__ <br />I am providing a boceh wth the to'lowr.o: (to protect my unpackaged food ono food props/atio- a/cat from (fees <br />dust and the putic) <br />[Ma booth wlh waits and co//>g cemtrucied of either wood, canvas, piastre, smhar nutteiiai *m f nt, f>z <br />otflering completely enclosing opei fcod areas k wit also f-ave » smooth and clranat>’«s focr (corr.refc, <br />asphalt, clean tarps and smooth wood are acceptable) nnd conah jeted to sepwate food and food prepwalon <br />Mem hear ibe pnHc <br />(_) Other (specify)________________.iU-> ..»■ —_________________________ <br />Electricity Is provided for my booth's use QLYes D No <br />I am provxlrg an accura’o proto lhermor alftr to moasure the hot «m1 coid hoMti'g of potMittaily ruuardows <br />foods durrg all t'mes of booth operation O Yes f~i No <br />I utn pnivKilnp ItHi Mowing Ml temperatme control *<x lhe hot hoklmg of ok potnntwliy hawntous foods abo.r <br />135‘F <br />I I Cmiv slave Btwno A batet trays <br />C Ooubte siaamer O Si <br />Qj Eloctoc stove top <br />Note: Examptes of potentially huardoua food Include: <br />vegetables, potato salad, eggs, and dairy products, <br />^e^e^Tcoranator th ^,0(^>,'n^0r’ Pr’:',‘1) B,c *'•’ ,Ou'n o ”«'*<! nhd compWerl copy of Pih < MCkIM v> <br />I.HwneotEwrt 1 ' ____Oete-. <br />The tolow^ig «s intormahcn abo-..! my orgjtowalorttbusress <br />Name of organualronbusross _£.tvlV <br />Address