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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />Completed by: 14. <br />Date <br />Paper Hand Towels <br />Cutting Board <br />Propane Stove <br />Propane Tank <br />Rinse Waler Bleach and WaterSoap and Water <br />Fire Exiinoutsher <br />Ice Cooler <br />1868 E. Hazelton Avenue I Stockton. California 95205 I T 209 468-3420 1 F 209 464-0138 I www.siqov.orq/ehd <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />t..... <br />Extra kx Bags 4 Food Containors must ba <br />storad 6 inches off of the ground! <br />5 Gal Hand wash <br />Wastewater Container <br />Garbage <br />Can <br />Booth must be on <br />Concrete. Asphalt. <br />Plywood, ora Tarp. <br />Sanitizer buckel- <br />bleach & water for <br />storing wiping doths <br />Extra <br />Water <br />SAN JOAQUIN <br />-----COUNTY------ <br />5-20 Gal. <br />Hand wash Water <br />Title <br />[^Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />[,/i One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />Paper towels and pump-style soap container. <br />Names of responsible persons to be present in booth during all hours of operation: <br />___________________________________________________ <br />“Important** <br />Health Permit <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45°F (if food is used the following day, maintain below 41 °F temperature): <br /> Ice chests Refrigerator <br /> Refrigerated truck Ice bath and tubs <br /> Other (specify)/ _______________________________________ <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />Three compartment sink. <br /> Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br /> Detergent, bleach, and wiping cloths (cleaning towels). <br /> Tub to store wiping cloths in bleach solution. <br />| Soap dispenser | ------------' <br />Sol <br />I <br />All food vendor4>ooths are subject to inspection. Please make a copy of this application in <br />preparation for this event. A copy of this checklist must be in the booth at all hours of <br />preparation anSoperation. Return original to festival coordinator three weeks prior to <br />this event. ( ] , . <br /> <br />/. Signature <br />(/ <br />Stemo w/Chaffing ___ <br />Dish