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Environmental Health Department <br />10. <br />11. <br />OR <br />t <br />12. <br />13. <br />Completed by:14. <br />I <br />I-CutUda I lunril <br />I lUoach <br />I <br />Ice Cooler <br />I <br />llro I <br />Water supply dispenser with warm water at a minimum of 100°F (i.o. 5-20 gallon container with spigot), <br />l/j One separate tub (bucket or basin) for the collection of rinso/wastowatcr. <br />[)(| Paper towels and pump-stylejpap container. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />□ I hree 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 />| Tub to store wiping cloths in bleach solution. <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />Tn Three compartment sink. <br />5 Gnl I hmd wash <br />Wastowator Contafnor <br />B-20 Gnl, <br />IIiiikI wash WaWr <br />Garbage <br />Can <br />SnnltUor buckot- <br />blondi A w.ilor for <br />Storing wlfiing cloths <br />Booth must be on <br />Concrolo, Asphalt. <br />Plywood, or a Tarp. <br />I tti.i Ice & I ckkI Cmit.ilncis must tm / <br />sfaiixf 6 inches <>// erf the ijimitul! ; <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 />__ <br />Stomo wAJIwiflinn <br />Dinh <br />Date <br />I'afior Ilurid luwnla <br />] <br />'VYxtvcvCX <br />Signature <br />| I’rupnno Innk <br />Title <br />Names of responsible persons to be present in booth during all hours of operation: <br /> <br />I I loalth Permit p <br />■"Important** <br />SAN.JOAOUIN <br />COUN I Y <br />(>i . t;l omv.1; In a' <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45°IT (if food is used the following day, maintain below 41T temperature): <br />Ice chests Refrigerator <br />(J Refrigerated truck [,J Ice bath and tubs <br />Q Other (specify)____ <br />.*>oap wul Wnlcr || Himo W.ilor | | lUoach nrxl Wntor | <br />1868 1.. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />I Hl > 16-02 | >.-1(10 H erf 11 I ( Ml > I VI NI Al >1' <br />0//3/I7 <br />| Soap ilisponsor