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HI©D <br />Name of Event:1. <br />2. <br />3. <br />4. <br />5. <br />/Average Age:6. <br />UTILITIES <br />1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />APPLICATION <br />1. <br />2. <br />Date: <br />TEMP EVENT APP <br />This application is to be completed and signed by the Event Coordinator, then returned to the <br />Environmental Health Department with all Food Vendor’s Applications no later than two weeks prior to the <br />event. <br />EHD 16-02 <br />7/14/15 <br />Is potable water supplied and available for each food vendor: <br />Is electricity supplied and available for each food vendor: <br />Are janitorial facilities available: <br />Number of toilets provided:V- <br />Name of sanitary garbage disposal company: <br />Method of disposal of liquid waste for food booths: <br />Submit the following to the Environmental Health Department two weeks prior to the event: <br />a) Temporary Event Application <br />b) Application Review Fee of $130 <br />c) Temporary Food Vendors Applications for each booth <br />d) Temporary Event Site Plan <br />e) Food Vendor List <br /> No <br /> No <br /> No <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/elftEB 2 2 2016 <br />Date(s) of Event: <br />Location: <br />Event Coordinator (Name): <br />Mailing Address: > <br />Number of Food Booths:L_____ <br />Approximate attendance at peak time: 0 <br />I understand that as a temporary event coordinator, I am responsible for meeting California State <br />standards and the Environmental Health Department policies and procedures. <br />Event Coordinator: <br />Page 1 of 11 <br />'S. Yes <br />E^Yes <br />!3'Yes <br />If the event is selected for inspection, the Event Coordinator will be billed for inspection time: <br />.• $130 per hour (weekdays 8:00 am to 5:00 pm) <br />• After regular business hours (weekday, weekends and holidays) the inspection is charged at the <br />hourly rate, calculated at one and one half times ($195.00 per hour) <br />TEMPORARY EVENT APPLICATION <br />To be completed and signed by Event Coordinator, then returned to the Environmental Health Department with all <br />of the Food Vendor’s Applications no later than two weeks prior to event <br />Total Attendance: ( <br />■ [I <br />f jTotCA-CA________ <br />—Telephone: (^t) V 7 <br />CA <br />GENERAL EVENT FILE INFORMATION <br />( - __________________ <br />2- ~ Time of Event: k/ ~rvt( A: © <br />Clt if-rkxj: m <br />a: » <br />■ilh' / Number of dumpsters: