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Environmental Health Department <br />Date(s) 1. Name of Event: 1. <br />2. <br />2471 N Naglee Rd Suite 100 #1030Address: <br />Alternate: (209Phone: <br />3. <br />4. <br />5. <br />( <br />6. <br />vegetables, potato salad, eggs, and dairy products. <br />22 <br />7. <br />8. <br />9. <br /> Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />SAN JOAQUIN <br />------COUNTY------ <br />Grcofneis grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />(773 ) 7081214 <br />List food to be sold or given to the public:. Tacos, Burritos, quesadillas. Nachos. Fries <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 /> <br />The following is information about my organization/business: <br />Name of organization/business: Los Primos Tex-Mex Food LLC <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgoworg/ehd <br />EHD 16-02 Page7of11 TEMPEVENTAPP <br />07/01/2024 <br />I am providing food that is NOT prepared at homejx] Yes EJ No <br />All food is prepared on-site or is from approved commercial facilitiesfx] Yes No <br />Name of facility: Comisaria Modesto Phone. (-------)-----------------------------------— <br />Address of facility: 1211 S 7th Street Modesto C A 95351 — <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br /> 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. ~ r H ! \ <br />Other (specif):FqqD TRUCK .!/ QAAVLA. (iCid I -4 <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 />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />[J Other (specify): Food Truck Water System <br />the h°'and coid hoidins °f potentially hazardousfoods during all times of booth operation:[x] Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp st ove Sterno & hotel trays Steam table & lids <br />[x] Double steamer Other (specify) <br /> Electric stove top <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br />) 8840192