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f S A N 10A Q U I N Environmental Health Department <br /> —COUNTY— <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors(both for profit and noh-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, 1.Name of Event:_Itmrfl daki-eoem a,idl,ai ^_ Date(s): <br /> 2. The following is Information about my organization/business: <br /> Name of organizationlbusiness: er<r+'■r.,},41e r., , <br /> Address: 1-6W)RrAnhllrn I n I ndt f_A 4S� Z„ <br /> Phone: ( 209 ) A„-MW ._ .__.._ Alternate:( } <br /> 3. List food to be sold or givers to the public; s <br /> 4. 1 am providing food that Is No prepared at home:❑Yes Q No <br /> All food is prepared on-site or Is from approved commercial facilities:❑Yes Q No <br /> Name of facility: Q,"ap fnM ki1rhan.AAr,'a r'r Ida rn Phone: <br /> Address of facility; i s&Q Rraalv,m 1 n 1 &r:A QS9d9 <br /> 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br /> dust and the public) <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.®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 /> 6. Approved water for drinking,utensil and hand washing will be provided in my booth by the following methods: <br /> ❑Approved bottled water. <br /> ❑Orr-site hose bib that is connected to a potable water source. <br /> ©Other(specify): NIA-all pranarka9arl fa <br /> 7. Electricity Is provided for my booth's use:❑Yes[jj No <br /> 8. 1 am providing an accurate probe themiometer to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation:Q Yes❑No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: 0 -Va he.,t nt&kj <br /> (]Camp stove ❑Stemo&hotel trays <br /> ❑Double steamer ❑Steam table&lids <br /> ❑Electric stove top ❑Other(specify) <br /> Notre: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E.Hazelton Avenue 1 Stockton,California 952051 T 209 46&3420 i F 209 464-0138 1 www.sigov.orag/ehd <br /> SM IS M Pape 7 of 11 TEW EVENT APP <br /> OW191la <br />