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• 4 <br />Environmental Health Department <br />Date(s):1.I.Name of Event: <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br /> Approved bottled water. <br />On-site hose bib that is connected to a potable water source. <br />9. <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APPPago? of 11 <br />7. <br />8. <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page 7 of 11 TEMP EVEN-! <br />07/3/17 <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. <br />LODI GRAPE FESTIVAL SEPT1 JI <br />SAIWOAQUIN <br />! * I® -----COUNT Y------ <br />\ x'4SCc^-- , <br />‘ Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br /> Other (specify): ____________________ <br />Electricity is provided for my booth’s use: 0 Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: 0 Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F; <br /> Camp stove Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br />The following is information about my organizatlon/buslness: <br />Name of organlzation/business: i b-------------------— <br /> Alternate: <br />List food to bo sold or glvon to the public: l'C€. <br />I am providing food that is NOT prepared at home: ^Yes No <br />All food is prepared on-site or Is from approved commercial facilities:^ Yes No <br />Name of facility: Phone: (------)----------------- --------------- <br />Address of facility: ....——-------------------------—-------:----- <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />|7J>A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br /> Other (specify):............ ...... —---------------- <br />Note: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: