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Environmental Health Department <br />I.Name of Event:1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br /> Other (specify): <br />6. <br />Approved bottled water. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <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 /> Sterno & hotel trays <br />O Steam table & lids <br /> Other (specify) <br />c v rc,\.€> 1 <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page 7 of 11 TEMP EVENT APR <br />07/3/17 <br />SAN JOAQUIN <br />i -------COUNTY— <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />0 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. <br />ed\ood and food-preparation areas from flies, <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />All food vendors (both for profit and non-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 />Ca< CoS u 6^ I <br />Name of facility: <br />Address of facility 4 I kJ V)-/A Tq - <br />I am providing a booth with the following: (to protect my unpackag' <br />dust and the public) <br />C On-site hose bib that is connected to a potable water source. <br /> Other (specify): /__________________________________________________________ <br />Electricity is provided for my booth’s use: 0 Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />/ <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />0 A AL CaS USa ztS <br />Alternate: ( )_ <br />List food to be sold or given to the public: y&^CcTA. |Cc^t>A <br />CX . I A|/ Date(s): 2-^ <br />I am providing food that is NOT prepared at home: Yes No <br />All food is prepared on-site or is from approved commercial facilities: Yes No <br />Name of facility: . ,T( SfPhone: {1 <br />The following is information about my organization/business: <br />Name of organization/business: Clt, < <br />(325)i8k28SYYi <br />- P.au w <br />.sjSzL^r- f