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SAN 10AQUIN Environmental Health Department <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br /> the festival coordinator three(3) weeks prior to this event. <br /> /A/l? <br /> 1. 1.Name of Event: y Liz 5 Date(s): <br /> 2. The following is information about my organization/business: <br /> Name of organization/business: f"n'I/ >2/S / 6- '� G­c/ S!lJ O Cj <br /> Address: �� z5a4-E­� l CE/��'pc./} �/� 9,j Z 2l�? <br /> Phone: ( Z(V) � 2 - D 3 S/ Alternate: <br /> 3. List food to be sold or given to the public: --LcE <br /> 4. 1 am providing food that is NOT prepared at home:NYes ❑ No <br /> All food is prepared on-site or is from approved commercial facilities:5]Yes❑No <br /> Name of facility: AV-11 Kcw s iTE �yam_Phone: 1 1 <br /> Address of facility: <br /> 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br /> dust and the public) <br /> N 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): <br /> Note: The only operations not required to provide enclosed booths are those which sell beverages from <br /> approved dispensers,or prepackaged foods from approved sources. <br /> 6. 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 /> I <br /> (g Other(specify): 11a1-D IVI %/��•,t <br /> I 7. Electricity is provided for my booth's use: [Z Yes❑ No <br /> 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation:4 Yes ❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: kllq <br /> ❑Camp stove ❑ Sterno&hotel trays <br /> ❑ Double steamer ❑ Steam table&lids <br /> ❑ Electric stove top ❑Other(specify) <br /> Note: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 18U,1 E Hazeltor�Avenue I Stockton, Califurnia 952051 T 209 468.3420 1 F 209 4b4 o138 I www.slgov.orgiehd <br /> EMO 1"2 Page 7 of 111 TEMP EVENT APP <br /> 06/?WQ23 <br /> I <br />