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s A NJ O A Q U I N Environmental Health Department - -C 0 U N!T 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. `�f�� n 1. 1.Name of Event,, JA 1.�Q5J�� `� Y V "� ' r `e`b ©ate(s):-__ h r.4 L�z1 2. The following is information about my organization/business: on I Name of organization/business: L. C_5_77�? Address:e_b -_E x bl V , 1kan " — QA L1t�� Phone: Alterrr�t�"(_"�-} 3. List food M be sold or divan to the public. 1 Z ZJq _--.-- 4. 1 am providing food that is NOT prepared at home: es❑ No All food is prepared on-site or is from approved commercial facilities: es❑ No Name of facility: bd h S I � l�1 r Phone: Address of facility: 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, dust and the public) Q?rbooth 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. ri rnv� water for drinking,u n„ sil a ter hinrn vLA! rr provided i tit booth 6. A,�,p,,,.,,d rlat., utensil and hand as..i..� l b pre. d n m, �t by the following methods: ❑Approved bottled water. ❑On-site hose bib that is connected to a potable water source. W<her(specify):_ ALAQ 7. Electricity is provided for my booth's use: ❑Yes❑No 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding at potentially hazardous foods during all times of booth operation:❑Yes❑ No 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 135°F: ❑ Camp stove ❑ Stemo&hotel trays ❑ Double steamer ❑ Steam table&lids Cj Electric stove top W015ther(specify) P I Z 2 a, bN e" Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, vegetables,potato salad,eggs,and dairy products. 1868 E. Hazeiton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd EHD 16-02 Pace 7 of 11 TEMP EVENT APP Miii9/79