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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />“Important** <br />14. <br />| I lealth Permit <br />Slomow/Choffinn <br />Dlat> <br />3 <br />1 / fco /lags A I'aodConlaiiwismust bu I'j <br />stoie-d C> Indios otl ol the fitoiintll .1 <br />Hlnsn Water | [ lllnnduvid Water | <br />/ l:xlr<i \ <br />Water <br />6 Gal I land wash <br />Wastewater Conlahmr <br />Garbage <br />Can <br />- - ttQ <br />Ice Cooler <br />| Soap dlsponsor <br />I I.'’ <br />Title <br />| Pnpor I land Towels | <br />/ Snrilllzor iHickot- <br />/ hlo.ir.h R water (or <br />/ I sloiing wlplny clolhs <br />F - | Booth must bo on <br />j i "/I Concroto, Asphalt. <br />All food vendor booths are subject to Inspection.. Mease make a copy of this application in <br />^m?n o^oin^^^al'coordlnator three weeks prior to <br />_______ <br />Date <br />5-20 Gal. <br />Hand wash Water <br />[ Dlonch ' <br />| Soap and Water <br />Uro I xtuKlulshor j <br />| I’lopanulunk <br />preparation for this event. A copy of this checklist must be in the booth <br />preparation and operation. <br />this event. <br />Completed by: --------------- <br />3 / \ Signature <br />| CiilUng Hoard <br />I’ropano Stow | <br />SAN JOAQUIN <br />- - COUNTY <br />( H .’.ifllr '.fl/OlV-. In I -! <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45T (if food is used the following day, maintain below 41T temperature). <br />|j<j Ice chests Cl Refrigerator <br /> Refrigerated truck Ice bath and tubs <br />O Other (specify).A.6&— <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />[/I Three compartment sink. <br /> Throe deep 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 water). <br />[Xl Detergent, bleach, and wiping cloths (cleaning towels). <br />0 Tub to store wiping cloths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />b0°111 P V^\»\cX vhAv'cukxz. <br />[/| Water supply dispenserwith warm water at a minimum of 100T (i.e. 5-20 gallon container with spigot). <br /> One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />|/| Paper towels and pumpistyle soap container. <br />Names of responsible persons to be present in booth during all hours of operation. <br />jo I ------------------------------------------------------------------------ <br />Hazoliou Avenue | Stockton. California 9520H | T 209 468-3^.0 | F 209 464-0138 | wv/w.sicrrhd.com <br />1.1 ID 16-02 Ph«o 00(11 <br />07/3/17