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:#- 2 J ,3 S AW]Q A Q U I N Environmental Health Department -- C UN�Y- All food vendors(both for profit and non-profit)are required to return a signed and completed copy of this checklist to the festival coordinator three(3)weeks prior to this event. S7"eJ'4 r 1. 1.Name of Event:)A n n4 eM Cross ro 41LA 5 C M ei es t,) Date(s):,SWIk6'4. 20 7-1 2. The following is information about my organization/business: Name of organization/business: Address h 6 X t C J an Phone: ( _? ZZ' Alternate: ( ) 3- List'food to be sold of given to public:c 4. I am providing food that is NOT prepared at home: W�Ies❑ No All food is prepared on-site or is from approved commer ial facilities: F`(es❑ No Name of facility: n M S 1 T�j (�LTr Phone: { } Address of facility: 5. 1 am providing a booth with the following. (to protect my unpackaged food and food-pre,_ -rafinn areas fr�ltTt flies, dust and the public) WOK"booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public, ❑ Other(specify): Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers,or prepackaged foods from approved sources. 6. Appfuvtjd wafer for drinking,utensil and harm washing will be ptovided it i nay bootl i by t-ze following methods: ❑Approved bottled water. ❑ On-site hose bib that is connected to a potable water source. �[ 1 Other(specify): O �V k ►`-+�- 7. Electricity is provided for my booth's use's❑No 8. 1 am providing an accurate probe thermometer t easure the hot and cold holding of potentially hazardous foods during all times of booth operation: es❑ No 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 135'F: ❑ Camp stove no&hotel trays ❑ Double steamer' ,� ❑ Steam table&lids pctrfc NIA- stove top ❑ Other(specity) Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, vegetables, potato salad, eggs,and dairy products. 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd EHO 16-02 Page 7 of 11 TEMP EVENT APP 0F,!19/19