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Environmental Health Department <br />10. <br />11. <br />OR <br />separate from utensil wash within my <br />12. <br />13. <br />‘‘Important** <br /> <br />Completed by: 14. <br />Paper Hand Towels <br />[ Soap dispenser j ------- <br />Ice Cooler : • <br />Garbage <br />Can <br />Slorno w/CliaffmO <br />Dish <br />Booth must be on <br />Concroto, Asphalt. <br />Plywood, or a Tarp. <br />SAN JOAQUIN <br />( • OU N I Y <br />d <br />Soap and Water | <br />/ xfru Ico Ilogs & l ood Containers must bo •] <br />v<:. <br />Signature <br />Rinso Water <br />Sanitizer bucket- I <br />bleach & water for | <br />storing wiping cloths <br />Bleach k. <br />rd: <br />Health Permit J'* <br />!> Gal I land wash I <br />Wastewater Conlamor I <br />| Propane Tank <br />Fire Txtinguishor <br />J Propane Stove <br />Zl I | I | <br />0 y.' <br />Title ~ <br />! 5-20 Gal <br />y- | land wash Water <br />Pp^!on anVoperZn <br />7 ________ <br />‘'Uatu <br />IUU r ——---------------- 77 . <br /> stored 6 Inches oil ol lhe gioundl <br />1868 E. Hazelton Avenue | Stockton. California 9520M#T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />(III) 16-02 <br />07/3/17 <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^rnaintam below 41 F temperature). <br />chests [Refrigerator <br /> Refrigerated truck LJ Ice bath and tubs <br /> Other (specify) ~ ~ — <br />I am providing the foliowing items within my booth for the sanitary cleaning of food preparation utensil <br />[ifThree compartment sink. <br />□ TO, .«p H~™». «• ““ <br />[.yTub to store wiping cloths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but <br />Rater feUenser^th warm'’wa^rt of wi>T (i.e^ 5-€o gallon container wth spigot). <br /> One separate tub (bucket or basin) for the collection of rinse/wastewater. <br /> Paper towels and pumprstyle^soap container. <br />Names of responsible persons to be present in booth during all hours of operation: <br /> <br /> <br />------------------------------------- --------------------