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Environmental Health Department <br />Date(s): <br />2. <br />Address: <br />3. <br />4. <br />5. <br /> Other (specify): <br />6. <br />9. <br />7. <br />8. <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 /> Stemo & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />EfApproved bottled water. <br />H^On-site hose bib that is connected to a potable water source. <br />Noto: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. <br />1. <br /> Other (specify):___________________________________________ <br />Electricity is provided for my booth’s use: H^Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: El Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />I.Name of Event: <br />The following is information about my organization/business: <br />Name of organization/business:. C.&xiAv/ <br />TT^S‘C(Mi <br />Phone: (^^ ) ~7 OHO? Alternate: ( ) <br />List food to be sold or given to the public: PU C7VKJ<P>y <br />I am providing food that is NOT prepared at home: [ZfYes No <br />All food is prepared on-site or is from approved commercial facilities: HYes No <br />Name of facility:Phone: ( ) <br />Address of facility: <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />BTa 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 />. SANJOAOUIN <br />f 7 ----COUNTY----- <br />' Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />meats, tamales, cooked beans, rice; <br />1068 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-34201 F 209 464-0138 | www.sjoov.oen/ehd