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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />•‘Important** <br />Completed by:14. <br />u <br />Ice Cooler <br />Garbage <br />Can <br />Sanilu-cr buckot- <br />bloach & water (or <br />storing wi(><(io cloths <br />Booth must be on <br />Concrete, Asphalt. <br />Plywood, or a I arp. <br />Storno w/Cb.i<ling <br />Dish <br />5-20 Gal. <br />Hand wash Water <br />SAN JOAOUIN <br />COUNIY <br />| Paper Hand Towels <br />V'l r <br />1868 E. I lazolton Avenue | Stockton. <br />(HO 16-02 <br />07/3/17 <br />1 V'CpV ';j <br />I xf/a /co llnys f. food Gontoinas must Ire •] <br />s/orcr/ 6 inches oil ol the groundl J <br />California 95205 | T 209 468-3420 | F <br />Pago 0 of 11 <br /> <br />nioach and Water <br />Qltloach jx. <br />I am nroviding the following cold temperature control for the cold holding of potentially hazardous foods below <br />45°F (if food is used the following day, maintain below 41 F temperature). <br />©Tee chests □Refrigerator <br />[Refrigerated truck LI Ice bath and tubs <br /> Other (specify)—— “ "" <br />P Propane Tank <br /> <br />209 464.0138 | www.sjcohd.com <br />I Health Perrriit |'J <br />j Cutsng Hoard <br />Propane Stove , <br />5 Gal Hand wash <br />Wastewater Container <br />I armproviding the foliovang items within my booth for the sanitary cleaning of food preparation utensil <br />[ujihree compartment sink. <br />H^mree deep tubs (basins 6-8 inches minimum) one for soapy water, one for nnsmg and one for a bleach <br />solution (one tablespoon of bleach per gallon of water)- <br /> 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 facilities, but separate from utensil wash within my <br />booth: <br />Cv^ater suppiy dispenser with warm water at a minimum of 100T (i.e. 8-20 gallon container with spigot). <br />[l^ne separate tub (bucket or basin) for the collection of rinse/wastewater. <br />[Raper towels and pump^stylejoap container. <br />......_____________________ <br /> <br /> sx “X=:.isss— <br /> Signalwt^/^ Tit,e________ Date