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Environmental Health Department <br />SEP 12.-15,2024Datc(s):1. <br />2. <br />Phono: <br />3. <br />4. <br />5. <br />6. <br />| | Approved bottled water. <br />| I On-site hose bib that is connected to a potable water source. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />SAN JOAQUIN <br />COUNIY <br />i< ;;; •. . hi !•. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />135T: <br />| | Camp stove <br />| | Double steamer <br />| | Hlcctric stove top <br />1868 1 I lazellon Avenue I Stockton. California 95205 | T 209 468-3420 | F 209 464 0138 | www.sjcchd.coni <br />lilllJIG O? PafloZofll II MPt;Vl Nl API’ <br />(1//.1/I7 <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 />I.Name of Event: <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />| | Other (specify): _—---------------- <br />Electricity is provided for my booth's use: M Yes [. I 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: Yes |.J No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above. <br />| | Sterno hotel trays <br />| | Steam table & lids <br />[ | Other (specify) <br />The following is information about my organization/businoss: <br />Name of organization/businoss: —----------—--------- <br />Address: JQ30 S dvdchins h Sve Loo'-f CA -------- <br />(20 9 ) Alternate: ( )----------------------------------------- <br />List food to be sold or given to the public: . eJ- .. <br />I am providing food that is NOT prepared at homo: ( J Yes | .J No <br />All food is prepared on-site or is from approved commercial facilities: Yes [J No <br />Name of facility: . fef/l/^L- Phone: .Gfe? )_747—-------- <br />Address of facilityC. Lo cke hfJ .<£1___/ad CA ---------------------------------------- <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flics, <br />dust and the public) <br />n A 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 cleanablo 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 />N Other (specify): 7/fl 74 / G <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 />Approved water for drinking, utensil and hand washing will bo provided in my booth by the following methods: