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Environmental! Health Department <br />the festival coordinate <br />1.I.Name of Evei Date( <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />nA <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home?tSl Yes No <br />All food is prepared on-site or is fromrapproved commercial facilities:^Yes No <br />Name of facility: S I (»j 0 LU Phone: (QiA) <br />Address of facility: UtpOj "Tlyiyfi SH"_______________________________________________ <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br /> 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 />Other (specify): ID X I D Q (LA (rft <br />Note: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved dispensersCoF^repackaged foods from approved sourc’esT^^ <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />SAN JOAQUIN <br />------COUNTY- <br />OrC.-' <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (bothJojipr^andJiQn-profit) are required to return a signed and completed copv_of this checklistto <br /> <br />Ql pcmMcu n j&t-Qi i <br />The following is information about my organization/business: <br />Name of organization/business: 0 (XfiS tYLr 11A QUA_______________ <br />Lv p 1 Thu (d Ri w tadc Lwu h'n aj -.To Caches <br />< 2-IA) ^1 Alternate: ( ) <br />-.VilAAMiiWwUa______ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />S!?,.1®'02 Pa9e 7 of 11 temp EVENT APR <br />U / / 0/1 t <br />®pther (specify): <br />Electricity is provided for my booth’s use: |~| Yes Nllxio 1x4 A <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 NJ A <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135OF: <br /> Camp^tove O Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top Other (specify)