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SAN JOAQUIN Environmental Health Department <br />Environmental Health Department <br />10 <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />11-1-25Mountain house block party1 Name of Evon Daie<«> <br />It <br />OK <br />Addrms <br />16192448618Phono(MlonuM (). <br />13 <br />"Important** <br />24 October 2025 Other Upectyi Compieiod by <br />Sioruturt <br />X. <br />Ice Gooiefmeat*. tamalM, cooked beans, rice. <br />I <br />Note: The only operations not reqcred Io prorale enclosed booths are those which soil bereraqes from <br />approved dispensers, or prepackaged foods from approved sources <br />AS food vendors (both for profit and non-profit) are required Io return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weoks prior Io this event <br />I provetng ttie Moerng lor adequate hnrw washog facilities, but separate from utmsJ wasli vetlvn my <br />booth <br />Names ot response<■ persons Io bo present m ooorh during ao ixxxs of oporation <br />Alnvi cartw cyan canof____________________________________ <br />■ Three deep tubs (basins 68 rxhes mnsrum). eno tor scstpy water, one lor rinsing and ore tor » breach <br />□Jbton (one taorospoon of beach per pa Ion of water) <br />^ketergent breaeh and wfpmg corns (clearing towels) <br />f Tub to Store wip«vg moths m bleach sokAcn <br />Geomnuu s«<n <br />Co^c*vte <br /><v a Tart <br />The foliOAnng is nformabon atxxrt my organization,'tusoess <br />.Carter six churros <br />GirtJQe <br />Cart <br />SAN JOAQUIN <br />COUNTY <br />booth with wsls and ceding constructed of either wood canvas plastic, sumiar material and fme mesh tty <br />Meenlng. completely enclosing open food areas It wit also have a smooth and cleanable floor (concrete. <br />aspb.»t. clean tarps and smooth wood are acceptable) and constructed Io scpiiratc food and food preparation <br />areas from the pubic <br />1668 E Hazelton Avenue I Stockton CaMomta 95205 I <br />tiow-w ’n- <br />LT__ <br />M I WmIV.* <br />All food vendor booths arc subject to inspection Ptoaso make a copy of Ous appKation n <br />preparason lor this event A copy of this ebeekkst must be in toe booth at al hours of <br />preparation and operation Return original (g festival COOrdfnator three weeks poor to <br />this event <br />I am provKlrvj the fo.icw.rg cokl temperature erntzot for the cold hoksng al pofontiaty han <br />*5 k |4 toed is used the follow eg day martam t»iow 4 Ck temperature;. <br />Ico chosis (“) Rclhgeralor <br />Q Refrigerated truck Ice bath and tube <br />C Other (speedy) <br />sXesDNo <br />Namecdtacddy Carter six churros p^ , , <br />Address of taokty qq „ hnllnsr, bsna mw mtnin hnnea ra 05301_______________________________ __ <br />I am provd ng a booth with the fonowog (Io protect my unpackaged food and food-preparation areas from flies <br />dust and the pubic.) <br />1866 E Hazelton Avenue I Stockton. Caidomw95205 | T 20-3 468-34201 F 209464-0138 I new t-igov onyohd <br />t.OiSW nw’vii rruPCvrHTAfw <br />orouztes <br />^proved waler lor dnnkng. ufensd and hand washing wil be provided in my booth by the loftowing methods: <br />Approved bottled water. <br />fesLJNo <br />ninety Io measure he hot and cold holding of potentially hazardous <br />on rjn'es(Z)No <br />Uurtrcontroi for the hot holding of ah potentially hazardous foods above <br />List food to be sow or given to the outKighurros. mini pancakes, dubaj strawberries <br />I am providng food that is HOT prepared at home □ YeH^No <br />AB food re propped orv-sfle or is from afiprovrd commercial (aohbes <br />Carter six churros <br />Name of oryMuzataxvtru <br />99 w bnlloso lane, mountain house, ca 95391 <br /> On-sne nose bib that is connected to a potable water source <br /> Otoe, (spixpfy) Generator <br />Electncty rs provtoed for my booth's useJjrYt <br />I am provromg an accurate probe toermafnetj <br />foods during all times of booth eperaton, <br />I am provxkng the following hot temperat <br />135‘F: <br /> Camp stove <br /> Double steamer <br />fecbic stove top <br />Note: Esamplee ot potantfaky hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br />C Sterno 4 hotel trays <br /> Steam table & Ids <br />Other (specify) <br />I am providing too follow ng terns vnttm my booth for the sar-tary cicanmq of 'col r.rcp.vaion utcns-i <br />D Three compartment smk <br />T 209 466-34201 F 209 464-0138 | wv.w s»>v otg'ehd <br />s«.| nUvlMWAW <br />Water supply dapenser with warm waler at a mramum of 100'F <i e 5-20 gNKn conlamer w-th spigett <br />s^nc separato tub (bucket or two) for too coBccWm of nnse.wastcwator <br />Paper towels and ourto-sMe soap ccrtaner