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Environmental Health Department <br />10. <br />11. <br />OR <br />separate from utensil wash within my <br />12. <br />13. <br />“Important** <br />14. <br />f ho I xtiiiflUlahof <br />------ <br />Ignature <br />Gnrbago <br />Can <br />Booth must boon <br />Concrolo, Asphalt, <br />Plywood, or a Tarp. <br />Snnllizor buckol- <br />Nonch A water for <br />storing wlpl<HI dolhs <br />.. l <br />loo Cooler | <br />[ Cutting Hoard ] • <br />I ’ropnno Stove <br />| | lllnnch mid Wntor <br />lixtra \ <br />Wntor I <br />5 Cal I land wash I <br />Wastewater Container <br />| | Hlnso Waler <br />Slomo w/Chn(fmg <br />Dish <br />| llloadi <br />| 1'iopnno Tank <br />20» >164-0138 | www.sjcohdS)(iii> <br />| Health Permit <br />| Soap dispenser | "■"I <br />SAN JOAQUIN <br />COUN I Y <br /> ice chests Refrigerator <br />□ Refrigerated truck □ bath and ‘ul]s r <br />□'Other (specify)jikei—ClOSdun-— <br />I om providing the foito^ng itenrs within rny booth for the sanitary ci^ <br />hree compartment sink. <br /> Three deep tubs (basins 6-8 inches °"c <br />solution (one tablespoon of bleach per gallon of w ). <br />[ | Detergent, bleach, and wiping cloths (cleaning towels). <br />[ j Tub to store wiping cloths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but <br />booth: <br />neater supply dispenser with warn, water at a minimum of 100T (i.e. 5-20 galion container Wth spigot). <br /> One separate tub (bucket or basin) for the collection of rinso/wastewater. <br />JzfPapcr towels and puniprstylc.spap container. <br />Names of responsible persons to be present in booth during all hours of operation: <br /> — Z= <br />All’food'vcndor booths are subject!0the booth at all hours of <br /> <br /> this ovont _____ <br /> Completed by: ----------- Title <br />I b-20 Oal <br />I land wash Wntor <br />'f <br />I I Soap nt'd Waterr <br />I x/m fcr; H.k/s « food ConMims musl bo <br />stoicrl fi Inchos off ol <ho urouiKlI <br />1868 li. I lazollon Avenue | Stockton. California 468 3/120 ' f <br />HID 16 02 <br />07/3/17 <br />for soapy water, one for rinsing and one for a bleach <br />I'npw I land Towels j