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Environmental Health Department <br />10. <br />Ch <br />lai11. <br />OR <br />I <br />12. <br />13.Nai <br />14.Completed by: <br />T re <br />Paper Hard Toweis <br />Soap Oi^wnsar <br />Cusig SosrS <br />Scad:Propane £to/= <br />ft.ft j*’' <br />Propane Tarft <br />Rfrwe Water <br />Ptr» SMIngdshcr <br />Ice Cooler <br />® Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />Q Detergent, bleach, and wiping cloths (cleaning towels). <br />□ Tub to store wiping doths in bleach solution. <br />jroviding the following items within my booth for the sanitary cleaning of food preparation utensil <br />tree compartment sink. <br />SGdHzndwadi <br />W&tewetef Ccntaner <br />Garbage <br />Can <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <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 fallowing day, maintain below 41°F temperature): <br />O Ice chests Q Refrigerator <br />O Refrigerated truck O Ice bath and tubs <br />□ Other (specify)_ <br />Swmo irfChaffir^ <br />Dish <br />5-20 Gid. <br />Ma.'id *ash wster <br />SAN JOAQUIN <br />-----COUNTY------- <br />SaniSzcr bucko <br />NtaotA W3ST toe <br />staSns wtoirtodwi*4 <br />< i <br />4 ■' <br />Health Permit <br />l am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />s/water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />S^One separate fob (bucket or basin) for foe collection of rinsefvrastewater. <br />sfpaper towels and pump-style soap container. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-34201 F 209 464-0138 } www.sjgov.org/ehd <br />EHD1WJZ PegeSoflt TEMP EVENT APP <br />06/29/2023 <br />rrC/ <br />Soep ar>6'N&let <br />Contents? rad to M <br />BkacSi and Water <br />if responsible persons to be present in booth during all hours of operation: <br />■h /ftfetha bi'-/ <br />**Important** Alt food vendor booths are subject to inspection. Please make a copy of this application in <br />preparation for this event A copy of this checklist must be in the booth at all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this event. /* /t <br />__^7 ~ eX f <br />Title Date J