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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />- T-lwDate(s):1. Name of Event: 1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />those which sell beverages from <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods:6. <br />9. <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APP <br />7. <br />8. <br /> Sterno & hotel trays <br />H Steam table & lids <br /> Other (specify) <br />Name of organization/business:___ <br />pipdl-frj <br />The following is information about my organization/business: <br />PreuoSiuS__________________________ <br />gUJP MeCfelloe <br />(qib ) So^ - oHTH Alternate: ( ) <br />List food to be sold or given to the public: Tf<03| f <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 />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />1858 E. Hazelton Avenue I Stockton, Ciiliforma 95205 j T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />1 „ _ r.. TCUD CX/CMT AlEHD 16-02 Page 7 of 11 <br />06/29/2023 <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: (^ H ) ^0^- 0^1 T'H----------- <br />Address of facility:: DO AU J fo, zJ ----------- <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 />Q 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): PoC(l flrd C K _ <br />Note: The only operations not required to provide enclosed booths are <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved bottled water. <br />Q9 On-site hose bib that is connected to a potable water source. <br /> Other (specify):_______ __ <br />Electricity is provided for my booth’s use: ® 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: 1X1 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 <br /> Double steamer <br /> Electric stove top