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Environmental Health Department <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />1. <br />2. <br />Address: <br />Phono: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />) <br />4 <br />7. <br />8. <br /> Alternate: ( <br />fv-nruA OxXeS <br />SANJOAOUIN <br />GOUN I Y <br />. . c;hi i-. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />U Other (specify): <br />Note: The only operations not required to provide enclosed booths <br />approved dispensers, or prepackaged foods from approved sour: <br />Approved water for drinking, utensil and hand washing will bo provided in my booth by tho following methods: <br />Datafst: SEP 12-15,2024 <br />> are those which sell beverages from <br />sources. <br />The following is information about my organization/businoss: <br />Name of organization/businoss: --------~ <br />lV f W CH <br /> <br />l ist food to be sold or given to tho public: <br />1808 ILItezellon Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 I www.sjcohd.com <br />I lli) Ki 02 Pngo /oMI <br />| | Approved bottled water. <br />[Xj On-site hose bib that is connected to a potable water source. <br />| | Other (specify):. -------------- -------- „- <br />a"d “ld h°ldi"3 °f f’ote,,,ially hazardous <br />i XXg too S“TtXo±S fir the hot holding of all potontia.ly hardens foods above <br />135T: <br />| | Camp stove I I Storno & hotel trays <br />| | Double steamer I. I Steam table & lids <br />1.1 l-'lectric stove top I J Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />the festival coordinator throe (3) weeks prior to this event. <br />1. Name of Hvont:. I.ODI GRAP!: 14-SI IVAt.____ <br />I am providing food that is NOT prepared at homo: I-N. Yes LJ No <br />All food is prepared on-site or is from approved commercial facilities: IX Yes No <br />Name of facility: _______________________Phone. (-----)------------------------------------ <br /> fam provWinTa booth with the following:: 7toprotect'my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />(Xf A booth with walls and ceiling constructed of cither 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 (ooncret, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public.