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{ 1 SAN,�.JUAQU N Environmental Health Department <br /> COUNT Y <br /> y Greotness grovrs here. <br /> TEMPORARY FOOD VENDOR'S APPLICATION <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 /> 1_ 1.Name of Event: aLjm, LA& � ' , GiiV ! Date(s): 10 - 1 q -- 'Ij <br /> 2.. The following is information about my organization/business: <br /> Name of organization/business: <br /> Address: �6 or-. j_ (_ A -- <br /> Phone: ( a,pco Q Alternate:{ ) <br /> 3. List food to be sold or given to the public: + <br /> 4. 1 am providing food that is NOT prepared at home: 0"Yes❑ No <br /> All food is prepared on-site or is from approved commercial facilities: [a Yes❑No <br /> Name of facility. C—o-"4'=� C'h-r• Phone: (20 —5L <br /> Address of facility: ')'TT)® ; t� 5A �( !a cam, LA C1 5S'6-j <br /> 5. 1 am providing a booth with the following:(to protect my unpackaged food and food-p <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> ples of potentially hazardous food include- meats, tamales, cooked beans, rice, <br /> vegetables, potato salad, eggs,and dairy products. <br /> 1868 E. Hazelton Avenue G Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwAq.sjgov.org/ehd <br /> EHD 1"2 Pays 7 of 11 TEMP EVENT APP <br /> 06/19119 <br />