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14-Sep-2017 18:30 4155340150 p.5 <br />Huj iu< <br />Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Date(s): <br />2. <br />Address: <br />Phone: <br />3.List food to be sold or given to the public: <br />•7 <br />4 <br />1 <br />5. <br /> Other (specify): <br />6, <br />On-site hose bib that is connected to a potable water source. <br />the hot and cold holding ot potentially hazardous <br />9. <br />meats, tamales, cooked beans, rice, <br />Received Time Sep. 1 4. 2017 4:21PM No. 2303 <br />7. <br />9. <br />Yes Q No <br />Phone: (__ <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />("I Approved bottled water. <br />SAN JOAQUIN <br />C OU N 'Y...... <br /> <br />ji p)H/foO ■// o fl <br />Name of organizatlon/business <br />.. <br />are required to return a signed and completed copy of this checklist to <br />Note: Examples of potentially hazardous food Include; <br />vegetables, potato salad, eggs, and dairy products. <br />Alternate; (,.^9 ) - " <£<5 <br />,,v A jsrr <br /> Other (specify). <br />Electricity is provided for my booth's use- S <br />I am providing an accurate probe thermrS <br />foods during all times of booth operation: <br />I am providing the following hot temperatun <br />135nF: <br /> Camp stove <br />M Double steamer <br /> Electric stove top <br />Not®; The only operations not required to provide enclosed booths are those which self beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />DLA booth with walls and celling 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 arid 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. <br />LYes(J No <br />[eter to measure <br />IQ Yes O No <br />f Control for the hot holding of all potentially hazardous foods above <br />O Sterno & hotel trays <br /> Steam table & lids <br />O Other (specify) <br />So Hazeftor' Av'enue I Stockton. California 95205 | T 209 468-3420 J F 209 464-0138 | ■wwwsicehd.com <br />07/3/17 P*«<’7 11 TEMP EVEN T APP <br />All food vendors (both for profit and non-profit) <br />the festival coordinator three (3) weeks prior to this event <br />1. Name of Event . z'Z^ q y tXZ 4? m./ *5 <br />The following is information about my arganiratlori/businsss.' <br />C ZCMtZZ Z, AT-Af ’Z <br />./h: .. <br />I am providing food that is NQT prepared at home: p^Yes O No , <br />All food Is prepared on-site or is tram approved commercial facilities: K." <br />Name of facility: ____________________________ _ <br />Address of facility ________ _ _________ _ <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from files, <br />dust and the public) <br />k/L aT 4 £4 AZS