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Environmental Health Department <br />Date(s): <br />2. <br />Address: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />SAN,JOAQUIN <br />-----COUNTY------ <br />are those which sell beverages from <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />o^e/w02 7 11 *CMP APP <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />to retum • 6lBned and “py of this checklist to <br />1. I.Neme of Event Date(s). Id^||<j <br />The following is Information about my organlzation/buslness: <br />Name of organlzation/buslness: T7C(/ T?H <br /> <br />Phone: Alternate^ ) <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home: ^fves No <br />All food Is prepared on-stte oj Is from approved commercial facilities: M Yes No <br />Name of facility: MA Phone: Ufoy 3 <br />Address of facility. /^2 // S-i <br />1 ^tandme publfcf f°,l n9: (t° protect my unPack»9®dand food-preparation areas from flies, <br /> A booth with walls and celling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screen ng completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete <br />areasfromfriepubH*^ Sm°Oth WOOd ar® acc8Pteb,e) and constructed to separate food and food preparation <br />Other (specify): <br />Note: The only operations not required to provide enclosed booths _ <br />approved dispensers, or prepackaged foods from approved sources. <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 />tjnDther (specify): 7^/7^ <br />Electricity is provided for my booth's use: Cj3?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: Nr 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 Stemo & hotel trays <br /> Double steamer Steam table & lids » <br /> Electric stove top (p Other (specify) N | <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products.