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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />LoVl Cov\i.Date(s): <br />2. <br />) W7V <br />3. <br />Phone: ( oWJ <br />5. <br />6. <br />water source. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />tote: Examples <br />vegetables, <br />I am providing foo I that is NOT prepared at home: [B'Yes No <br />All food is prepare lon-site or is from approved commercial facilities: (gf Yes No <br />Name of facility: ' ” ' __________________ <br />Address of facility: foPLO/ CA <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies. <br />Phone: <br />List food to be sold or given to the public:'IbTS <br /> Stemo & hotel trays <br />0" Steam table & lids <br />) pother (specify) fufT - TbP GflUL <br />of potentially hazardous food include: <br />potato salad, eggs, and dairy products. <br /> Approved bottle j water. <br />^p6n-site hose bit • that is connected to a potable <br /> Other (specify):____________ <br />Electricity is provide d for my booth's __ <br />am providing an iccurate probe thermometer <br />foods during all ti nes of booth operation: (3 Yt.. <br />ai35P’FV'din9 the 0ll0win9 h0t temP0ratlJre control for hot holding of all potentially hazardous foods above <br /> Camp stove <br /> Double steamer <br /> Electric stove to <br />are required to return a signed and completed copy of this checklist to <br />1868 6. Hazelton Avenue <br />EHD 16-< 2 <br />06/18/19 <br />dust and the put lie) <br /> A booth with w ills 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 />a^ha jtetean <aT s and smooth wood are acceptable) and constructed to separate food and food preparation <br />fc>6£> <br />All fcod vendors (both for profit and non-profit) are requiu <br />the festival coordinator t iree (3) weeks prior to this event <br />I.Name of Event: <br />use: [^Yes No <br />. r to measure the hot and cold holding of potentially hazardous <br />--------Yes No <br />| Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Page 7 <*11 TEMP EVENT APP <br />The following is in brmation about my organization/business: <br />Name of organiza ion/business: kllCfJCM <br />Address: 1>UX>CXy DcvT), SflcMWn-ro , CfA <br />(^ <br />Note: The only o orations not required to provide enclosed booths are those which sell beverages from <br />approved d spensers, or prepackaged foods from approved sources. <br />Approved water foi drinking, utensil and hand washing will be provided in my booth by the following methods: <br />Upt /loT) <br />Alternate: ( ) <br />Wvj'WI-'7iP 6/Wi) <br />— . ------ ------------------■■■■» —ouici nww, vanvaa, piaauu, similar material ana Tine mesn riy <br />screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br />areas from the put lie. <br />[Q'Other (specify):