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Environmental Health Department <br />SEPTDate(s):I.Name of Event:1. <br />2. <br />Address: <br />3. <br />4. <br />5. <br />6. <br />0 Approved bottled water. <br />®. On-site hose bib that is connected to a potable water source. <br />9. <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APP <br />7. <br />8. <br />135°F: <br /> Camp stove <br />0 Double steamer <br /> Electric stove top <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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 />LODI GRAPE FESTIVAL <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Pago 7 of 11 TEMPEVENl <br />07/3/17 <br />I am providing food that is NOT prepared at home: IXL Yes No <br />All food is prepared on-site or is from approved commercial facilities: [Kl Yes f J No 's <br />Name of facility:Phone: (-------)----------------------- -------------- <br />Address of facility:_—------------------------ <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. <br />Xl Other (specify): <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 /> Other (specify):_________________________________________________ <br />Electricity is provided for my booth's use: ® Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: [H-Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Sterno & hotel trays <br />]$ Steam table & lids . <br />©.Other (specify) <br />The following is information about my organization/business: <br />Name of organization/business: <br />A/, <br />Phone: (-^7) Alternate: ( 2^) <br />List food to be sold or given to the public: 7^^ <br />SANJOAOUIN <br />r ------COUNTY— <br />reCI 1 0 e 5 5 .9 r0 ,V 5 ''ei e- <br />TEMPORARY FOOD VENDOR’S APPLICATION