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Environmental Health Department <br />10. <br />( <br />it <br />OR <br />12. <br />13. <br />“Important** <br />Completed by:14.Title <br />Health Permit <br />PmxJ ttond rrwwi-« <br />PraoJM Stow <br />it <br />Pror.ooo 1 an« <br />“7 <br />zz_ <br />KintW <br />fllo-no wiV.I.«ir«tg <br />Ooh <br />& Gnl I l»nd *»»li <br />WmlMmW ConUlnet <br />Sanif M' <br />Oteach tw*Hi <w <br />jUinn,; wtptng doth* <br />Booth muni bu on <br />Conwoto. Asphalt, <br />Plywood, ora lorp. <br />borp dupMitot <br />I am providing the following itoms within my booth for the sanitary cleaning of food preparation ulonsil <br />Q Throe compartment sink. <br />-- <br />Gnmage Cnn <br />SANTAQUIN <br />COU N TV — <br />I am providing the following cold temperature control for the cold holding of potontinlly hazardous foods below <br />45*F (it food Is used the following day. maintain below 4IT temperature): <br />□ Tea Chests OR'ofrigerator <br />n Refrigerated truck [J Ice bath and tubs <br /> □ Other (specify). <br />slnnil OUkIioi o! Uii O'Olinil <br />I co Cooler : I? <br />I Rloscn <br />; j OhKhKPdWKW <br />Wiki | <br />□ Throe deep tubs (basins 6-8 inches minimum), one (or soapy water, one for rinsing 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 />I am providing the following for Adequate hand washing facilities, hut separate from utensil wach within my <br />booth: <br />Q^i/ater supply dispenser with warm water at a minimum of 100T (l.o. 5-20 gallon container with spigot). <br />□ One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />1868 E. Hazelton Avenue | Stockton. California 05205 | T 209 468-34201 F 209 464-0138 | ^ww.sjgoworg/eh^ <br />EH010-02 PafloBwII <br />08/19/19 <br />□ Paper towels and purrip-style.sppp container. <br />Names of responsible persons to bo present In booth during all hours of operation: <br />Al u/ ----------------------------— <br /> <br />All food vendor boUlh^ro subject talnB'pectlon. Please make a copy of this application In <br />preparation for this event. A copy of this checklist must bo In the booth at all hours of <br />preparation and operation. Return original ts foldMl coordinator thr<?P vmk». g£lQLi2 <br />this ovent^r?-^/ — - y t 7 . <br />Signature Title Date