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Environmental Health Department <br />10. <br />11. <br />OK <br />12. <br />Names13. <br />14.iture <br />5 (kill Inrxl wnsh <br />Wnalowntar Conl.ilnor <br />Garbage <br />Can <br />fi-20 Oal. <br />I land wnsh Wirtor <br />Booth must bo on <br />Concrclo, Asphalt. <br />Plywood, or a Tarp. <br />--- ---------- <br />Ice Cooler <br />[ PoporllntidTowols <br />I xbn lec Ihtis f. / <»x/ Cwrf.iftio/s musl bo •.'] <br />stofed 6 Indios oil ol Iho (itotincll <br />Stomow/Chnffinn <br />.....JI <br />1868 l.\ I lazolton Avenue | Stockton. California <br />1111)10 o? <br />0/13/17 <br />- | | Hmso W.v.or | | llloachnndWnlM <br />( f -xlrn \ <br />Walor I <br />•osponsiblc per^oj <br />♦‘Important** <br />| propanaYMk ..Z2:r; <br />Soap ivwi Wnlor <br />Uro I xllnpuhhor | <br />[ inooch <br />j Crop.ioo Stuvo <br />- 209 468-34201 F 209 464-0138 | www.s^M.com <br />Pago B of 11 <br />SAN JOAQUIN <br />COUNIY <br />, am providing tho foiling cold temperature control for tho cold holding of potentially hazardous foods below <br />45T (if food is used tho following day, maintain below 411- temperature). <br />□ ICO chests [Refrigerator <br />□ Refrigerated truck L J Ice bath and tubs <br />□ Other (specify) <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />| $4hree compartment sink. <br />□ hhree 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 />(•<4 Detergent, bleach, and wiping cloths (cleaning towels). <br />Jj^j_rub to store wiping cloths in bleach solution. <br />I am providing tho following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />Cuttuhl Hoard | .. . <br />| -1 Water supply dispenser with 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 />(tf Paper towels and pumprstylc soap container. <br />p/o bo present in booth during all hours of operation: <br />------------ ------------------------—-------------------- <br /> <br /> Completed by: ----------------- -------------Title Dat° <br />SaniU/or buckot- <br />liloach «. wator (nr <br />storing wiping dotlis <br />| | loalth Permit |«