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S A N.DJ O AQ U I N Environmental Health Department � t COUNTY r Gteatneti 9faws her# TEMPORARY FOOD VENDOR'S APPLICATION Ali food vendors(both for profit and non-prord)are required to return a signed and completed copy of this checklist to i the festival coordinator three(3)weeks prior to this event_ ' 1. 1.Name of Event: foAW% Ayw -A�VYw V�): ZO _ y ZZ 2. The following is information about my organizabontbusiness: Name of organizatiorubusiness: 9 1 Address: b ' S Phone: ('Z10.) 5 '_-" - Alternate: ( ) 3. Ust food to be sold or given to the public:_i100d► f�Er�- �� ------- 4. 1 am providing food that is NOT prepared at home:J'Yes❑ No All food is prepared on-site or is from approved commercial facilities:Zi Yes❑No Name of facility: _ � c- - Phone: Zq " Address of facility:SS- �A C [ rU'C' .RAG Cf .0 151 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from files, dust and the public) sA booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly creening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, asphalt clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public. ❑other(specify): Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers, or prepackaged foods from approved sources. 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: Approved bottled water. 0 on-site hose bib that Is connected to a potable water source. ❑Other(specify): 7. Electricity is provided for my booth's use: YesE No 8. 1 am providing an accurate probe therm meter measure the hot and cold holding of potentially hazardous foods during all times of booth operation:P Yes❑No 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 135°F: ❑Camp stove [)Stemo&hotel trays ' ❑Double steamer Steam table&lids Electric stove top Other(specify) u X)CLA 6C aVV1 Note: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, vegetables,potato salad,eggs,and dairy products. 1868 E. Hazelton Avenue I Stockton, calif6mia 952051 T 209 468-3420 C F 209 464-0138 I + .sjgoM. d EN©16-02 Page 7 of 11 06M W19