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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />“inipoit.iiit** <br />14. <br />Slgnaturo <br />[ I Hom h <br />fl <br />I co Cooler | <br />| C.uIUiiii llo.irJ | . <br />Stow <br />ft G.il Haiul V.MU <br />Wmlow.ilrr CuiXimiiw <br />Gnrhnoo <br />Can <br />Boolli nuisl bn on <br />Conciolc. Asplmll. <br />Plywood, ot n I mp <br />b-zo G.il <br />I hind v/.uli VVnlof <br />SAN JOAQUIN <br />(. < )U f l I Y <br />IBGBk. I kizttllonAvomiPl Stocklon. California 96205 | I 209 468-3420 | I' 209 464 0138 | www N9ov;‘>'4)/ol''J <br />cudiii.oz. pufloiioin tlmpevi.ni aip <br />oil/1 IM 10 <br />[ I’npot llnnil rov.iil> <br />| I r.|. I..-, I n ■' I <br />.^’7 <br />I loallh Ponnlt : <br />/ I SanUizer bucknt- <br />/ Unadi A wnlci tut <br />/ ! ' ktmlnt) »<p'ng dotlis <br />I am providing tho following cold lomperakiro control for llio cold holding of potentially hazardous foods below <br />45vf (if food Is used tho following day, maintain below 41 “I' lomporalnro): <br />t3lco cliosls Refrigerator <br /> Refrigerated truck Ice ball) and tubs <br /> Other (spoclfy)„i^//^__Ci*Z/_C^.^---------------------------------------------------------------------------------------- <br />| Slotno wtGlinffino ___, <br />(Hili I <br />umnii uo.iru | ------ - I <br />j A \ I IJITLI^ | <br />i . UiL <br />I | oOAp nn<! Welnr | J |<in>u E lllencli uml Wni'i | I <br />| rim hulinfluiihor | / \ Q <br />I---------------------------------1 / I xlr,, \ <br />W.iloi | <br />r-\'» ■ ■' 1 . •. <br />I alm Ico Muys Z / <>■></ Cuubi.'iii'i.K musl Im <br />ahuoil C Indiov ull ol Iho yioundl i <br />I am providing tho following Homs within my booth for Iho sanitary cleaning of food preparation utensil <br />[”] Three compai tmont sink. <br />Three (loop 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 waler). <br />[ | Detergent, bleach, and wiping cloths (cleaning towels). <br />[21 Tub to store wiping cloths In bleach solution. <br />I am providing Iho following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />I^VVator supply dispenser with warm water nt a minimum of 100T (i.o. 5-20 gallon container with spigot). <br />Ono separate tub (bucket or basin) (or tho collection of rinso/wastowalor. <br />[^fT’apor towols and pump-stylo soap container. <br />Names of responsible persons to be present In booth during all hours of oporalion: <br />_____________________________________________________ <br />All food vendor booths aro subject to Inspection. I'lease make a copy of this application In <br />preparation for this event. A copy of this checklist must bo in tho booth at all liouis of <br />proparatlon and operation. Return QiJcihia.l_Jto__fostlv£il_coor£|lll«?t£?r-ttll'.wooksjirlor to <br />thlsXnfont, ' _ <br />Complotod by: _________ ___________________ <br />/ (/ Slgnaturo Htlo Date <br />b-20 fi.il <br />I I lnn<l w.uli W«iiu< I