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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />"Important** <br />Completed by: 14. <br />Signature-5?^ <br />niiino w.itor7 <br />Ice Cooler <br />y/ t Q' f <br />Title <br />vl <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />[ixl^Vator supply dispenser with warm water at a minimum of 100T (i.o. 5-20 gallon container with spigot). <br />|l/l^no separate tub (bucket or basin) for the collection of rinsc/wastcwater. <br />I iJT^apcr towels and pump-style_spap container. <br />I'xli.i Icoll.iga A loodConUilnotxmust Iw <br />slomd 6 hichos off nt the fiiuiuxll \ <br />Storno w/tllinflino <br />IM-ill <br />5 -20 Gul. <br />Hand wash Water <br />Garbage <br />Can <br />Booth must be on <br />Concroto, Asphalt, <br />Plywood, or a Taip. <br />1868 I Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | I- 209 464-0138 | www.sjcehd.com <br />1111)1(1-02 P.ige U«i( II ll-MI’I Vf Nl API’ <br />(I//.VI/ <br />SANJOAQUIN <br />COUNIY <br />( 'll «’UI hf'C <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, rjiaintain below 41°F temperature): <br />[’Chee chests [kl'Refrigerator <br />[/IpRefrigerated truck O Ice bath and tubs <br />Q Other (specify) <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />fkrfhree compartment sink. <br />I^Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solulipn (one tablespoon of bleach per gallon of water). <br />I ZHletcrgont, bleach, and wiping cloths (cleaning towels). <br />I j Tub to store wiping cloths in bleach solution. <br />Jww7’ez <br />I Sonp mid Wnter <br />I im lixtliigulslMr <br />j I'lop.uKi :;tovo <br />| Sioiip dispon.nor | . <br />| lllouch <br />| I’ioi'.iim I link <br />Names of responsible persons to be present in booth during all hours of operation: <br />. \ /\ / 6 d < c Y_' / 'C'f-'-x___________________________ <br />All food vendor booths arc subject to inspection. Please make a copy of this application in <br />preparation for this event. A copy of this checklist must bo in the booth at all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this event. ,------....................................... " 5-/7- <br />Date <br />| Cuttitig llcuird J . <br />| I lealth Permit p <br />J I'aiiorllnnd 'lowcli | <br />SaniUzor buckol- <br />l>lo.id> K wnlor for <br />stodnQ wiping cfoOis <br />.< <br />I Blench mid Wnlw <br />J> Gal Hnnd wash <br />Wnntewalnr Contnlnor