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Environmental Health Department <br />Datefs): I.Name of Event1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />1 <br />I <br />5. <br /> Other (specify): <br />6. <br />0. <br />meats, tamalts, oooked Mans, rlo®, <br />IS <br />• -x <br />7. <br />8. <br />Noto: 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 /> Stemo & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />"tew <br />SAN JOAOUIN <br />------COUNTY------ <br />Greotness grows hr?rc, <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Noto: Examples of potentially hazardous food Include: <br />vegetables, potirto salad, eggs, and dairy products. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />^Approved bottled water. <br />On-site hose bib that is connected to a potable water source. <br /> Other (specify): <br />Electricity is provided for my booth’s use: [ <br />I am providing an accurate probe thermo <br />foods during all times of booth operation: <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />EiCamp stove <br />JzfDouble steamer <br /> Electric stove top <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 , i i <br />II <br />Yes No <br />eter to measure the hot and cold holding of potentially hazardous <br />fl Yes No <br />fork- ____ <br />The following is information about my organization/business: <br />Name of organization/business: Esr^lonyouiviCou^K^Ttoill <br />PO tyox z ca J _________ <br />D *1 l~l 0 1____________ Alternate: () U 0^0_____ <br />List food to be sold or given to the public: TYPTip f Samsa a Xs <br />I am providing food that is NOT prepared at home: (^Yes No <br />All food is prepared pn-site or is from approvedpommercial facilities: Yes No <br />Name of facility: 0 ftlfK T/fe ^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 />M 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 />1868 E. Hazelton Avenu&j Stockton, California ©52051 T 209 468-34201 F 209 464-0138 | www.staov orafehd