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� 'N 10 ALU U I N Environmental Health h Depclt'•t: ill t <br /> 1U. 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 /> ❑Ice chests ❑Refrigerator <br /> ❑Refrigerated truck Ice bath and tubs <br /> 910ther(specify).-WI -- - <br /> 11. 1 am providing the following items within my booth for the sanilwy cleaninL1 of food preparation utensil <br /> L]Three compartment sink. <br /> OR <br /> ❑ Three deep tubs(basins 6-8 inches minimum),one for soapy wntnr, cine for rinsing and one for a bleach <br /> solution (one tablespoon of bleach per gallon of water). <br /> XDetergent,bleach,and wiping cloths(cleaning towels). <br /> 1_]rub to store wiping cloths in bleach solution. <br /> 12. 1 am providing the following for adequate hand washing facilities,but separate from utensil wash within my <br /> booth: <br /> Watersupply dispenser with warm water at a minimum of 100'F(Le.5-20 gallon container with spigot). <br /> CJ One separate tub(bucket or basin)for the collection of rinse/wastewater. <br /> Wpapor towels and pump-style soap container. <br /> 13. Names of respons le persons to be present in booth during all hours of operation: <br /> "Important" All 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 nd peration. <br /> 14. Completed bY:..-... --- -- -gPXYIUv( -- -,9, 0�`--. <br /> Signature Title Date <br /> ... y,•R'::l _. SIO(301...... <br /> I Walth Pormlt — �t annd wnah wolo. <br /> �' Papur I lantl Ywaola <br /> Cul4ng Elgirtl — I-__SareBnrluckel- <br /> _ hWuh 8 wawior ' <br /> -k3,CnUr <br /> $WN w0nq dolha <br /> _ Booth n,usl be on <br /> Concrete, Asphall, <br /> -- - ��`• Plywood,or a Tarp. <br /> soot'and walCr ,li1190 Wates 4Fgneh ped Wee, <br /> Garbage <br /> rrr�rxlkv�+dsimr <br /> Wal._ <br /> Ice Cooler <br /> Cxrru kcAnya d raa0CdnlaFnra rnuat m ti Wast" c u <br /> 1868 E. I-lazelton Avenue I Stockton,California 95205 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br /> CHO If-07 Pnya 8 at 11 TEMt'LWNT APP <br /> 07131:7 <br />