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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />2. <br />7/ <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br /> Other (specify): <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods:6. <br /> Approved bottled water. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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 />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />EHD 18-02 Pago 7 of 11 TEMP EVENT APP <br />06/10/10 <br />SAN JOAOUIN <br />-—COUNTY----- <br />Date(s): <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 />I.Name of Event: <br /> On-site hose bib that Is connected to a potable water source. <br />Efother (specify): fap d - ) <br />Electricity Is provided for my booth ^-use: 0 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: 0 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 Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top Q'dther (specify) <br />The following Is Information about my organlzatlon/buslness: <br />Name of organlzatlon/buslness: Z^1/ <1 i S Pi <br /> <br />( ) 3 3 ^6 7.00 Alternate: (7c/ <br />List food to be sold or given to the public: <br />I am providing food that Is NOT prepared at home: Ezfves □ No <br />All food Is prepared on-site or Is from approved commercial facilities: Yes No <br />Name of facility: Phone: (M ) <br />Address of facility: /2,5 6 Lilli^ui Avf, f 5c? I Ch___________ ___________________________ <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 />0 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.