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10 <br />11. <br />OR <br />from utensil wash within my <br />12. <br />13. <br />“Important** <br />Completed by.Title1-1. <br />I <br />LJIce Cooler <br />5 20 Gil <br />HanUw.istiWatoi <br />1068 I <br />| .it> b <■? <br />SAN JOAQUIN <br />i .•util ' <br />Stomp |. <br />I <br />Cco_______^ate 1 <br />5 tl.-u ••.V’ I A''-1' | <br />V. rfc*J''I <br />Booth must bo on <br />Concrete. Asphalt <br />Plywood, or a Tarp <br />----j <br />Garbage <br />Can <br />Cusng ] — <br />T <br />| Health Permit o l ( I’opcr Han i tiM. h | <br />S.kj! rn' lur*ol I <br />1 IcicTi ft water lor I <br />ifonr’] w.png cJottn I <br />I <br />I Ivlion Avonu.-1 Slo..klm. Cabfornra 9i.20!.J T <br />L. | I <br />).. f. l.'^l <'Ue <br />ft . ■ ' ■' < •' <br />Wlthin my booth for fho sanitary cleaning of food preparabon utensil <br />; ' 209.|(i8-3«0| P 209 .164-0138 | vvww sjcohd com <br />Pair C cl tt <br />S' <br />______ _ .—\------------1 <br />| | lM,eW.»!.-r | | lne.Ki.avlW.-w J <br />I 1 IV.jtw I <br />• C.lf .>:.rA.VW <br />fee I .mg .hlcr ] <br />i am providing the following items <br />M Three compartment sink. <br />n Three deep tubs (basins 6-8 inches minimum) one for soapy water, one <br />solution (one tablespoon of bleach per gallon of water h <br />Detergent, bleach, and wiping cloths (cleaning lowc s). <br />Sjub to store wiping cloths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but separate <br />^ler supply dispenser with worm water at a — Of WOT (i.e. 8-20 gaiion container with spigot) <br /> one separate tub (bucket or basin) for the collection of rinse/wastewater. <br />SQ’aper towels and pjjmpjLslyle_sp_ap container. <br /> <br />preparation for this event. > <br /> <br />preparation and opcration^/RcL--------— <br /> / / Signature <br />Environmental Health Department <br />| I , i r... I m <br />for rinsing and one for a bleach <br />—r“...... <br />n ice chests ^Refrigerator <br /> Refrigerated truck L1 •« bath and tubs <br /> Other (specify)—