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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />5-20 gallon container with spigot) <br />13. <br />■“important** <br />Completed by:14. <br />Paper Hand Towels <br />Soap dispenser <br />Culling Board <br />Bleach <br />Propane Stove <br />7% <br />Propane Tank <br />Bleach and Water <br />Fire Extinguisher <br />' F temp event afPage e of 11 <br />■ ■________________________________________________________________________________________________- <br />Health Permit <br />Q 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 />^ Detergent, bleach, and wiping cloths (cleaning towels). <br />L^Tub to store wiping cloths in bleach solution <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br /> Three compartment sink. <br />sterno w/Chaffing <br />Dish <br />Extra <br />Wate> <br />5 Gal Hand wash <br />Wastewater Container <br />5-20 Gal <br />Hand wash Water <br />Booth must be on <br />Concrete. Asphal’ <br />Plywood, or alar <br />Sanitizer bucket­ <br />bleach & waler lor <br />stonng wiping cloths <br />Title <br /> One separate tub (bucket or <br />p^j Water supply dispenser with warm water at a minimum of 100 F (i.e. <br />basin) for the collection of rinse/wastewater. <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45°F (if food is used the following day, maintain below 41°F temperature) <br />0Tce chests Refrigerator <br /> Refrigerated truck Ice bath and tubs <br /> Other (specify) <br />Ice Cooler J •■mu n rr~ir r~rT“rr <br />I E>tro leu Bogs 4 Foort Contmno'S must be <br />---------- -- • 1 stored 6 inches oil o< tl>e ground' <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />0*Paper towels and pump-style soap container <br />Names of responsible persons to be present in^booth during all hours of operation <br />----------------------------------- <br />EHP IM2 <br />WIWW <br />Garbage <br />Can <br />this event <br />Date <br />Soap and Waler Rinse Wa,er