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1 <br />Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />**lmportant** <br />Completed by: 14.DateTitleSignature <br />Health Permit <br />Papor Hand Towels <br />Soap dispenser <br />Bleach <br />Propane Stove <br />f <br />Propane Tank <br />Bleach and WalerSoap and Waler <br />Fire Extinguisher <br />Ice Cooler <br />TEMP EVENT APP1868 E. Hazelton Avenue | Stockton, California 95205J <br />EHD 18-02 p?=” <br />07/3/17 <br />Extra /ce Bags i Food Conlalnots must be <br />storvd 6 Inches off o! tho gnundl <br />Stemow/Chafflng <br />Dish <br />Garbage <br />Can <br />Sanitizer bucket­ <br />bleach 4 water for <br />storing wiping cloths <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />5 Gal Hand wash <br />Wastewater Container <br />-"IT 209 468-3420 | F 209 464-0138 | 'A^-Si^dxorn <br />Pago 8 of 11 TE"" <br />• .jj <br />5-20 Gal. <br />Hand wash Waler <br />one for rinsing and one for a bleach <br />SANJOAOUIN <br />------COUNTY------- <br />Greotness grows here. <br />Tam 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 O lce 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, <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 />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />□ Water supply dispenserwlth warm water at a minimum of 100"F (i.e. 5-20 gallon contalnerwith spigot). <br />□ 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 />Cutting Board -------- <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this event.