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Environmental Health Department <br />I'■»/• <br />All food vendors (both for profit and non-profit) arc required to return a signed and completed copy of this checklist to <br />1. <br />2. <br />3. <br />4. <br />(>. <br />6. <br />9. <br />moats, tamales, cooked beans, rice, <br />7. <br />B. <br />Approved bottled water. <br />(>( On-site hose bib that is connected to a potable water source. <br /> Other (specify):____ <br />Note: The only operations not required to provide enclosed booths <br />SAN JOAQUIN <br />• COUNTY-- <br />t/i i‘h: re <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Cjontvee^iQAS .. <br />HZ353: <br />)hu6')ctSH-425R <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 bo provided In my booth by the following methods: <br />the festival coordinator three (3) weeks prior to this event. <br />I.Name of Rvent: ^5155^531^ <br />The following is information about my organlzation/buslnoss: <br />Name of organization/business:. CXjA <br />Address: P.O- Pov <br />Phone: ( ) Alternate: ( <br />l ist food to be sold or given to the public: --------------- <br />18(58 P.. Hazelton Avenue | Stockton. California 95205 | I 209 468-3420 | I- 209 464 0138 | www.sjcoh(l com <br />P.mo/oMI TEMPEVENIAII <br />07/3/17 <br />I am providing food that is NOT prepared at home: tXI Yes I 1 No <br />All food is prepared on-site or is from approved commercial facilities. KI Yes | ] No <br />Name of facility:___________________________Phone: {-------)----------------------------------- <br />Address of facility:.............................-----------------------------------------------------rr-- ;-----------;;------------7" ’ ;iirt <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from tlies, <br />dust and the public) <br />[XI 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 cloanablo floor (concrete, <br />asphalt, clean tarps and smooth wood arc acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />|* J Other (specify):-----------------------------------------------------------------------——----------------------------- <br />Electricity Is provided for my booth's use: D4 Yes I...I 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: [XJ Yes [ J No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: ‘ p/A - MO <br />| | Camp stove I I Stcrno & hotel trays <br />| | Double steamer I I Steam table & lids <br />[ | Electric stove top I. J Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products.