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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />“Important** <br />Completed by: 14. <br />I <br />Ice Cooler <br />.I <br />lira I xlinfluhilwr <br />Garbage <br />Can <br />Booth must bo on <br />Concrolc, Asphalt. <br />Plywood, ora Tarp. <br />Saniliznr iHickol- <br />Hoach A w.itor tar <br />storing wiping doths <br />Storno w/Chnfting <br />Disli <br />| f'ropnno Tnnk <br />| INoach <br />Health Hermit <br />209 464-0138 | www.sjcehd.com <br />SAN JOAQUIN <br />COUN I Y <br />I am pmvlding'the fonowing cold temperaturerx^ £.cold ho^of potentially hazardous foods Mow <br />45T (if food is used the following day. maintain below 41 F temperature). <br />|X| Ice chests ^Refrigerator <br /> Refrigerated truck LI,cc bath and tubs ______ <br /> Other (specify)------ ------------------------------------------------- - “— <br />LiCKZL <br />Soap nrwl Wator I <br />... <br />| CUSng ttowd | - <br />| I’ropano Slovo | <br />| Soap rllsponsor | --------- <br />j I’npor I lanrl lowols | <br />Hl,iso Water | | (Mondi mul Wnlor | <br />( lirfrn \ <br />Water <br />.M 5 Oal I Innrl wash ----------- <br />H wastewater Container■ I I xlr.ilcoll.rgsAroadCA^Mnorsnunllio ' <br />storerl C Inc/tos oil ol U>o Qioundl <br />1868 E. I lazelton Avenue | Stockton. California 95205J T,209 468-3420 | F <br />1 .1II) 16 02 <br />0 7/3/1/ <br />Kothlt ho'us of <br /> and'oporZn. ^coo^natoHhre^^rior Jo <br /> ------------------------------------------------ Signature <br />______ <br />Title <br />5-20 O.al. <br />Hand wnsh Wator <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />M Three compartment sink. <br />□ Ttiree deep tubs (basins 6-8 inches minimum) one for soapy water, one for rinsing and one for a bloach <br />solution (one tablespoon of bleach per gallon of water). <br />I I Detergent, bleach, and wiping cloths (cleaning towels). <br /> Tub to store wiping cloths in bleach solution. <br />, am providing the following for adequate hand washing faculties, but separate from utensil wash within my <br />booth: <br />M| water supply dispenser with warm water at a minimum of 100T (i.e. 5-20 gallon container wfth spigot). <br />y]| one separate tub (bucket or basin) for the collection of rinse/wastewater. <br />P Paper towels and p_ump-style soap, container. <br />Names of responsible persons to bo present in booth during all hours of operation: <br />------- -------------------------