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Environmental Health Department <br />10. <br />11. <br />for rinsing and one (or a bleachOR <br />12. <br />13. <br />‘•Important** <br />Completed by:14.Signature <br />3II'lro I xtliioulal’or <br />Ice Cooler <br />209 464-0138 | www.sjcohd.com <br />n MPl .VCNI Al’p <br />!iGnlHnn<lwash <br />Wnahwntnr Cont.ilnnr <br />Sanlltzor Inickol- <br />blondi ?• w.-itor for <br />storino wiping cloths <br />Booth must bo on <br />Concroto, Asphalt, <br />Plywood, or a Taip. <br /> <br />Slorno w/Clinflirif) <br />Dish <br />Garbago <br />Can <br />r"/ <br />I >//a Ico ll.7(|S & IV'XI GoiiMiv* "K'.'li'o <br />| Soap dlsponsor | -------- <br />| lllonch <br /> | | nioachnndWnlor | <br />I I xlru \ <br />Wator <br />a | <br />sloiccl 6 lochos oil ot tho Uiouncll I-’ <br />■1868 II lazollon Avenuo | Stockton, California 95^1 TM9 468-3420 | F <br />I-.III) 16 0? <br />07/3/17 <br />Soap mid Water | <br />[ I’ropano Tank <br />| Pnpor I land Towols <br />| Rmpano Stovn <br />SAN JOAQUIN <br />COUNI Y <br />' ssKMassssRSS' “ ““ <br />(vf Ice chests □Refrigerator <br /> Refrigerated truck Ice bath and tubs <br /> Other (specify) <br />, ..providing the following items within my booth for the sanitary deaning of food preparation utensil <br />[vrhrce compartment sink. <br /> Three deep tubs (basins 6-8 inches minimum) one for soapy water, one <br />solution (one tablespoon of bleach per gal on of water). <br />[“] Detergent, bleach, and wiping cloths (cleaning towels). <br />( | Tub to store wiping cloths in bleach solution. <br />t am providing the following for adequate hand washing facilities, but separate from utensii wash within my <br />booth:l^atorsupply dispenser with warm water at a minimum of 100T (i.e. 5-20 ga.ion container with spigot). <br /> One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />IT^aportowels andp_umB^ty!esggBcontainer. <br />Names of respo^rso^^present in booth during all hours of operation: <br />,i? rs-ssas:J’" S 2 SS" - <br /> _ <br />I 6-20 Gnl. <br />. - | HnndwndhWatof <br />| Health Permit |/- <br />_JL-. <br />i . 7„...../.. .ir .7 <br />Rlnso Water