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Environmental Health Department <br />10 <br />11. <br />OR <br />12. <br />13.ames of responsioie persons tc <br />Completed by:14. <br />Health Permit <br />Paper Hand Towels <br />Propane Stove <br />Bltach and WaterRnaeaterSoap md Water <br />Fire Exhngiidw <br />Stemo w/Chaffing <br />Dish <br />Extra <br />Water <br />Garbage <br />Can <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />0 Three compartment sink. <br />5-20 Gal. <br />Hand wash Water <br />Sanitizer bucket­ <br />bleach & waler for <br />storing wiping cloths <br />Ice Cooler p <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />gfWater supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />[g^One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />H^Paper towels and pump-style soap container. <br />••Important** <br />□ Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />^Detergent, bleach, and wiping cloths (cleaning towels). <br />0 Tub to store wiping cloths in bleach solution. <br />SANJOAQUIN <br />------COUNTY------ <br />Greotness gro»vs here. <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45T (if food is used the following day, maintain below 41 "F temperature): <br />[■] Ice chests 0 Refrigerator <br />® Refrigerated truck 0 Ice bath and tubs <br />® Other (specify)----------------------- -------------------------- --------------------------------------------------------------------------- <br />5GalHand wash <br />Wastewater Container <br />Names of responsible persons to be present in booth during all hours of operation: <br />I ataraddtehoaoffofthagrmndt y.,, I <br />Smton.CatiftMnia 952^ 209 468-34201 F 209 464-0138 | www.sjgovW^ <br />I Cutting Board <br />All food vendor booths are subject to inspection. Please make a copy of this application in <br />preparation 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 three weeks prior to <br />this event , . <br />Signature Title Date <br />Soap dispenser <br />Bleach