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Environmental Health Department <br />10. <br />11. <br />OR for rinsing and one for a bleach <br />12. <br />13. <br />“Important** <br />Completed by:14. <br />I’oporHand Towol* <br />Soap d tpcntot <br />Cutl-no Uoo»d 3 [fHOiidi <br />I'rop.WB Stavo <br />r-■F-- <br />l*(O|M'i« Tiirk <br />I no t-xlingusslior <br />TFMP EVENT API’Pago Oof 11 <br />Exira <br />Walor <br />SOmtland wnaM <br />W.Mlow.ilor Conl.witr <br />Garbage <br />Can <br />Sanibzcr buckoi- <br />blooch & waler for <br />etortno wiping doihs <br />Jlcmov/Chaliing <br />Osh <br />■ ■_ .-("tnyry r- ■. <br />Health Permit -I <br />SAN JOAQUIN <br />( .'IIl\ I I <br />Title <br />r-t r i ■ i •. r • ••■* •*'• > • ■ ~ <br />i:>trj Ico Hogs A I oed ConUmcis mini bo ' <br />stored 6 inclici off ol the groundl <br />J <br />lzl <br />Ice Cooler <br />am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />I Three compartment sink. <br />__1 <br />Soap and Water Rmso Walor <br />Booth must bo on <br />Concrete, Asphalt. <br />Plywood, or a Tarp. <br />____________ <br />cu r: x < <br />Signature <br />$ <br /> Three deep tubs (basins 6-8 inches minimum), one for soapy water, one <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 />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />|§] Water supply dispenser with warm water at a minimum of 100T (i.e. 5-20 gallon container with spigot). <br />Q One separate tub (bucket or basin) for the collection of rinse/wastewater. <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, maintain below 41T temperature). <br />Q} Ice chests '0 Refrigerator <br />[ ] Refrigerated truck LI Ice hath and tubs <br /> Other (specify)__ ________________________________ <br />1868 E Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcchd.com <br />(W1G-0? Pago 0 0(11 TEMP EVENT <br />07/3/17 <br />0 Paper towels and pump-style soap container. <br />Names of responsible persons to be presenj in booth during all hours of operation^ cS <br />QlzJ <br />All food vendor booths are subject to inspection. Please make a copy of this application in <br />preparation for this event. A copy of this checklist must be in the booth at all hours of preparation and operation. Return original to festival coordinator three weeks prior to <br />this event. n 2 'A <br />------- ' Date