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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Pol, k FfAeL V- <br />Datefs) 1.' Name of Event <br />2 <br />Address: <br />3. <br />a Q <br />4. <br />5 <br />6. <br />9. <br />Note: ExampiM of potentially hazardous food Inckida:maate. tamates, cooked baans. rice. <br />vegetable*, potato salad, ago*, and dairy products. <br />'■ <br />1 <br />)_________________— <br />SVHCtM hiz s <br />7. <br />8. <br />O 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 />' ■vcd water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />-^Approved bottled water <br />G- -jte i tose bib that is connected to a potable waler source. <br />lorxls during all times of booth operation: Yes O No <br />I arr. ; _ <br />135T: <br />' 1 Camp &ove <br />J Double steamer <br />Electric stove top <br />Al. 'ood vendors (both for profit and non-profit) are required to return a signed and completed copy of this checkhs! to <br />the. test vai coordinator three (3) weeks prior to this event , / <br />V ./-LxCzy) OH I }C < » k Datefs) f <br />H azcJlon Avenue | Stockton. California 95205 | T 209 468-3420 J F 209 464-0138 | ww.^j| <br />rho i64)2 "... ‘/j’r-'-.-T? r-A”' <br />07/0172024 <br />■ <br />Otner (specify) _________________________________________________ <br />■. leclncity is provided for my booth's use: KJ Yes U No <br />vr providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />J « • • • • " VMM• * ~ »»»I ~' — • <br />pro /iding the foliowing hot temperature control for the hot holding of all potentaHy hazardous foods above <br />D Stem© & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />l am providing food that is NOT prepared at home^ Yes O No <br />All food is prepared on-site or is from approved commercial facilities ^Yes O No <br />Name of facility. Kr \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 />Tj A booth with wails 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 cteanable 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 />s <br />The following is information about my orgenlzation/business <br />Name of organtzation/business . "IQ C12 k. (1^4" V <br />Phone (3£j I <4 52 Alternate: ( <br />List food to be sold or given to the public: ^51 Hvcd I -j