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Environmental Health DepartmentSAN JOAOUIN <br />10 <br />11. <br />OR <br />12 <br />13. <br />Completed by:14. <br />Health Permit <br />CxS-gSc«t <br />tap <br />Ice Cooler 3 <br />HMPEVtNTAPPP»g»8of H <br />SOaf <br />WWMMvCflrtamr <br />5KTO RfOtMVlQ <br />Q*t <br />G^ge <br />Can <br />Mmc* taato'IW «*«^<**" <br />Bcoei mue t>« on <br />Concnto. AipMt. <br />Ptyocod. ora Tarp.U~U'LJflJ <br />IlNttriWMr <br />I am providing tfio following cold temperature control for the cold holding of potentially liarnrdoue foods be <br />45T (If food is used lhe folowing da^/malntatn below 41 *F temperature) <br /> ice chests 0Refrigerator <br />EfRefngerated truck Ice bath and tubs <br /> Other (specify)-------------------------- ---------------------------------------------------------------------- <br />ImX providing the following items within my booth for the sanitary cleaning of food preparation uto <br />S 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 stere wiping cloths in bleach solution <br />I am prewd^g the followmg for adequate hand washing fadkties. but separate from utensil wash within my <br />xoth: <br />dVater supply dapenser with warm water at a minimum of 100’F (l.e. 5-20 gallon container with spigot). <br /> One separate tub (bucket or basin) for the collection of rinse/wastewater. <br /> Paper towels and pump-style soap container <br />Nr^es ofrespcnsible persons tobe al< houre operation:_________________ <br /> ^fSd'venStobte1’^ to inspection. Please make a <br /> <br />p—SXXrS <br /> ' ^SlgrfaJre Title Date <br />I M I <br />r- I I <br />. xrwd < ncAM tM <br />IBM E. Hawi on Avw.ua | Stockton. California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgoww^ehd <br />ot’vr