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S A N 10 A Q "W Environmental Health Department <br /> —_ COUNTY___SP 15 20-17 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> TEMPORARY EVENT APPLICATION <br /> To be completed and signed by Event Coordinator, then returned to the Environmental Health Department with all <br /> of the Food Vendor's Applications no later than two weeks prior to event <br /> GENERAL EVENT FILE INFORMATION !n� <br /> 1. Name of Event: L'i�ornvrnjyti�- IRtC,- W1 Kalim 00-ti y-M kxv_,:� 11e <br /> 2. Date(s) of Event: n2t I- 2a7 Time of Event: I1)Aw —1or�m U <br /> 3. Location: r"k_hke ►[ �� T� - <br /> 4. Event Coordinator(Name): 13P r1 cr�oo i Telephone: ( ) c��-45b'� <br /> Mailing Address: ,.Igo. afj n2 a n_52 <br /> ' <br /> 5. Number of Food Booths: NOylN a*'.°� JnP oJ (;Je f»-iQI <br /> 6. Approximate attendance at peak time: )a_OA2n Total Attendance: 1 Average Age: O"4v <br /> UTILITIES <br /> 1. Is potable water supplied and available for each food vendor: ❑Yes ❑ No <br /> 2. Is electricity supplied and available for each food vendor: ® Yes ❑ No <br /> 3. Are janitorial facilities available: rr Yes ❑ No <br /> 4. Number of toilets provided: R P_ rw-v SIi-e Coo <br /> 5. Name of sanitary garbage disposal company: d7b Number of dumpsters: �- <br /> 6. Method of disposal of liquid waste for food booths: 4,Qb <br /> APPLICATION <br /> 1. Submit the following to the Environmental Health Department two weeks prior to the event: <br /> a) Temporary Event Application <br /> b) Application Review Fee of $152 <br /> c) Temporary Food Vendors Applications for each booth <br /> d) Temporary Event Site Plan <br /> e) Food Vendor List <br /> 2. If the event is selected for inspection, the Event Coordinator will be billed for inspection time: <br /> • $152 per hour(weekdays 8:00 am to 5:00 pm) <br /> • After regular business hours (weekday, weekends and holidays)the inspection is charged at the <br /> hourly rate, calculated at one and one half times ($228 per hour) <br /> This application is to be completed and signed by the Event Coordinator, then returned to the <br /> Environmental Health Department with all Food Vendor's Applications no later than two weeks prior to the <br /> event. <br /> I understand that as a temporary event coordinator, I am responsible for meeting California State <br /> standards and the Environmental Health Department policies and procedures. <br /> Event Coordinator Date: 90/ A, /? <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 16-02 Page 1 of 11 TEMP EVENT APP <br /> 07/3/17 <br />