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Environmental Health Department <br />10. <br />12. <br />13. <br />14.Completed by: <br />I'lipw IlniKf Towols <br />7 Itoiso W.itor I llnnch nn<l Walnr <br />( l-xlm \ <br />Wntor <br />!> (>nl I faiKl wnsh <br />Wn.Mow.ilor Conlnlnnr <br />Garbago <br />Gau <br />Sunilizor buckot- <br />bloach A wnlor for <br />storing wfplng cloths <br />Booth must bo on <br />Concrete, Asphalt. <br />I ’lywootl, or a Tarp. <br />6-20 Gal. <br />I land wnali Wnlor <br />Slorno w/l'liiining <br />Dish <br />" Title <br />| Boap dispciuoi <br />| llloadi <br />Names of responsible persons to be present in booth during nil hours of operation: <br />....M/' t J- t fA '*1x___________________ ________ ________ __________ <br /> <br />**lmportant** <br />..1.fi <br />Ice Cooler | | <br />11. I arn^roviding the following items within my booth for the sanitary cleaning of food preparation utensil <br />[/fThrce compartment sink. <br />OR <br />1868 I-. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) I- 209'164-0138 | www.sicohd.com <br />ii/H/f/’02 I’ageBolll II Ml1 l-VI Nl Al’B <br />Ml/.»/ I f <br />SANJOAOUIN <br />COUNIY <br />(<l ■•<il <)!<>GS lute <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 daw maintain below 41T temperature): <br />I I Ice chests ^^Refrigerator . z‘ c>/H At . <br /> Refrigerated truck |J Ice bath and tubs <br /> Other (specify) <br />[ J 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 />IZl Tub to store wiping cloths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />X / A ’• b A fj /’/i/Zc <br />[/1 Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />I I Ono separate tub (bucket or basin) for the collection of rinse/wastewatcr. <br />[pfPapcrtowels andpump-stylospap container. <br />J: j >1^7 „ <br />| Soap nod Water | | <br />rim I'xtlnpulslior | <br />/Z/'z' J. Li Ant >_______________________ ____________________________ <br />All food vendor booths arc subject to inspection. Please make a copy of this applicalioTTin <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 ,£^., JAl <br />' Signature <br />| I’mp.ino lank <br />f xfta kc Hags A l oad Cmitakms must ho <br />xlomd C Inches all ol tho gtoundl <br />^Pate y <br />I I loalth Permit <br />| Cutting DoiNd j . . <br />j I’rop.mo Stovo J