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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />signed and completed copy of this checklist Io <br />I .Nainc of livent.I. <br />2 <br />Address <br />Phone. <br />3 <br />4 <br />!>. <br />IIlose which sell beverages from <br />(>. <br />{ I Approved hotlh'.d water. <br />(he hoi and cold holding of polent'cilly ha/aidous <br />9 <br />|vf A booth Vv-ilh walls and ceiling <br />I*t ^z*l/*cif <br />asphalt dean tarps and smooth wood <br />areas from the public. <br />7. <br />(5 <br />SAN JOAQUIN <br />( I . I.) ■ I I > <br />(he festival coordinator (hi no (3) weeks prior to this evenl <br />lODKIRAPI-l-TSIIVAI <br />All (cod vendors (both for profit and non-profit) mo required to return a <br />| | Othoi (specify): ■ <br />Note: The only opci aliens not required to provide enclosed booths arc <br />approved dispensers, or prepackaged foods from approved sources. <br />Appr oved wale, for drinkmg. utensil and hand washing will be provided m my booth by thn following methods- <br />|)atc(S): S' •’ M-,Z 7023 <br />IMHtl | || Mclkr- Avmiui' | Stm l ton. ' ..Jiloini/ !>!••?(>!. ( I I U‘.i <br />• •n <br />Pi n; I I 20'1 •'<>1 lll'oi I WWW )• < >hl ■ oill <br />It '.l-'i . til At'l- <br />\)4 On site hose bib that is connected Io a potable watei source. <br />| | Olher (specify) . _ .. ■ <br />l-lectr icily is provided for my booth’s use. os i I No <br />I am providing an accurate piobe (hcimomeler Io measure <br />. XS XXXXXnx1. X hot boKlln, or „« .......... lo^s oOovo <br />135 |- <br />| | Camp stove I I Slcrno A hotel bays <br />| J Double steamer '/i table & lids <br />1 •Iccliic stove top I I Other (specify) <br />Note: l-’xamplcs of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />I he following is information about my organization/busmess: <br />NameoforcMnization/businoss. < 0 <br />^“7^-^.26^ Alternate^ ). . .............. <br />I ist food to be sold or given Io the public...... .. ............... . ............................... <br />...., constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />=—• ...—X £'“S; <br />I am providing food that is NOT prepared at home: 1X1 Yes I I No <br />All fond is prepared on-site or is from approved commercial facilities: |)d Yes | | Mo <br />Name of facility: ...................... 1 hone. ( —). .............................. <br />^n'prXkfing'a booth with the following: (to protect my unpackaged food and food-preparation areas from Ums. <br />dust and (he public) <br />meats, tamales, cooked beans, rice.