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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Date(s): 10/26/20241. <br />2 <br />1Address <br />Phone <br />3 <br />4 <br />5 <br />6 <br /> Approved bottled water. <br />9 <br />meats, tamales, cooked beans, rice. <br />7 <br />8 <br />1808 E Hazelton Avenue | Slur Mori <br />LHO 1C-O2 <br /><X»W20ZJ <br /> Other (specify):_ <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 be provided in my booth by the following methods <br />List food to be sold or given to the public: <br />The following is information about my orgamzatiorvbusmess <br />lyAlXM <br />1x3 .J Y’tjuv'-t P-c4 <br />Note: I-------,----- - . <br />vegetables, potato salad, eggs, and dairy products. <br />Calilornia 95205 I 1 209 468-3420 1 F 209 464 0138 | www Sjgov oig ehd <br />Pjya/otll UMPEVENTAPP <br />[^)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 cleanable 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 />Name of orgamzation/business <br />O O Alternate; ( ) <br />I am providing food that is NOT prepared at home: Yes Q No <br />All food is prepared on-site or is from approved commercial facilities 0 Yes No <br />Name of facility: ^3 -L'l/i f C 7^ C Phone. ( Q? 7 6 *9 Q <br />Address of facility ----------- <br />I am providing a bcferth with the following: (to protect my unpackaged food and foo<#>reparation areas from flies, <br />dust and the public) <br />rx On site hose bib that is connected to a potable water source. <br /> Other (specify) _—- --------—------------------------------------------------------------------------------- <br />Electricity is provided for my booth's use LJ Yes Qg No <br />I am providing an accurate probe thermometer to measure the tiot and cold holding of potentially hazardous <br />foods during all times of booth operation. SiYes No <br />I am providing the following hot temperature control lor the hot holding of all potentially hazardous foods above <br />135-F <br /> Camp stove [^pSterno & hotel trays <br />O Double steamer D Steam table & lids <br />O Electric stove top I 1 Other (specify) <br />Examples of potentially hazardous food include: <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 />1 Name of Event; Mountain House Diwali Mela 2024