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Environmental Health Department <br />O Three compartment <br />OR <br />12. <br />13. <br />important** <br />14. Completed by: <br />DateSignature <br />Heafth Permit <br />PaparHtMTcwtfo <br />SowdipanMr <br />Cuafla&MiS <br />Propane SIM <br />0cKJ <br />Proper* Tar* <br />BiMen and wear <br />Ice Cooler <br />TEMPEVEHTAPP <br />Water supply dispenser with warm water at a minimum of itXTF (i.e. 5-20galfon corrtajner with spigot). <br />One separate tub (bucket or basin) for the collection of rinseZwastewater. <br />SttmowCM«n9 <br />Okh <br />Garbage <br />Can <br />Exira k» S<f> < exjd ConMnan muU t* <br />tsond 6 tt ejea <br />6Gd Hand wuft <br />WaaMatwCcrMnar <br />Sw*MrtucScM. <br />MwshawMrfcr <br />MMtaQ wiping etamc <br />^Paper towels and pump-stvlo kmd container. <br />Hames of responsbte persons to be present in booth during aS hours of operation: <br />Booih must be on <br />Concrete, ABphab. <br />Plywood, or a Tarp. <br />SAN JOAQUIN <br />COUNTY <br />I WMCh <br />Soap ura Waar <br />10. lam providing the foltawing cold temperature control for the cold holding of potentially hazardous foods below <br />45*F (if food Is used the foltawing day, matatain below 41T temperature): <br />Sice chests Refrigerator <br />O Refrigerated truck Ice bath and tubs <br />O Other (specify)- __ ________ <br />Afl food vendor booths are subject to infection. Please make a copy of this appUcatfon in <br />preparation for this event A copy of thia checkfist must be in the booth at all hours of <br />preparatton and operation. Return cKtalnM to fatttval cpordlnstor three weeks prior to <br />______ll '2.2^. <br />•n«e___________Date <br />K <br />1i. lam providing the foltowing items within my booth for the sanitary cleaning of food preparation utensil <br />MC GM <br />Q Three deep tubs (basins 6-8 Inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water), <br />g Detergent, bteech, and wiping cloths (cleaning towels). <br />0 Tub to store wiping doths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />VUmVi** | <br />A <br />18B8E. Hazelton Avenue | Stockton, California 952051 T 209 468-34201 F 209 464-0138 | www.sjcahd.com <br />EHD 10-02 p*9® 0 <br />0TW17 <br />rx J ^- I :Ln