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SAN JOAUUIN Environmental Health Department <br />10 <br />11. <br />OR <br />12. <br />13. <br />’’Important’* <br />Completed by: 14. <br />TitleSignature Date <br />Health Permit <br />Paper Hand TowcJs <br />Soap dispenser <br />Cuting Board <br />BleachPropane Ssove <br />Di u1— <br />Bleach and Water <br />Fire ExUr.Qvieher0 <br />Ice Cooler <br />£jrfr» /ce Beja 4 Food Coniunort muit bo <br />itcsod fi mchoi of! oltho ground' <br />All food vendor booths are subject to inspection. Please make a copy of this application in <br />preparation for this event. A copy of this checklist must be in the booth at all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this event. <br />Stemo w/Chaff.ng <br />Dish <br />5 Gal Hand wash <br />Wastewater Container <br />Garbage <br />Can <br />Sanitizer becket­ <br />bleach 4 water for <br />storing wiping clod's <br />Booth must be on <br />Concrete. Asphalt, <br />Plywood, or a Tarp <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />AS’F (if food is used the following day, maintain below 41°F temperature)’ <br />Ice chests Refrigerator <br /> Refrigerated truck Ice bath and tubs <br /> Other (specify) _____ <br />Propane Tank <br />V <br />Rinse Water <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />t] Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />'ID One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />© Paper towels and pump-style soap container. <br />Names of responsible persons lo bp present in booth during all hours of operation: <br />_____________________________ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.Sjgov.org/ehd <br />EHD 16-02 Page 8 of 11 TEMP EVENT APP <br />06/18/19 <br />S-20 Gal <br />Hand wash Water <br />at) o. <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br /> Three compartment sink. <br />Three deep tubs (basins 6-8 inches minimum), one for 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 /> r i I, 7 <br />Soap and Water <br />Extfa <br />Waler