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Environmental Health Department <br />e Date(s): 2. <br />*4 <br />) 3. <br />4. <br />5. <br />6. <br />connected to a potable water source. <br />7. <br />8. <br />9. <br />meats, tamales, cooked beans, rice, <br />^40 sanwoaouin <br />X “COUNT Y------ <br />‘•ir(MWim/ss yrrmt /htp. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />JfX SJ X“t0 reU,m 3 sl0"«> 3"3 «Wed copy of this ehsekltst to <br />1.Name of Event: A/ <br />— —r <br />The following Is Information about my organlzatlontalness: <br />Name of organlzation/business: j <br />Address: 73/Z <br />Ph°ne:t , -------- ---------------- Alternate: ( <br />Ust food to bo sold or given to the public: 'Tirvi ^.,r <br />fc°<l ** PraP3red * tm“- □ No <br />Name of facZ^^? z7 ^7^ faCl,itle8: ° No <br />Address of feoflity: <br />dusU^ tte pu^jb (t0 Protedmy unpackaged food and fLd^reparation areas from files, <br />SJnfoTfa^Xs* k 37 “r38, PlaStlG'S,mllar and fine mesh fly <br /> Other (specify); <br />th°Se W“ ** bovera*s •»" <br />^^^d^ng.utens.ood^^^,,^^^^^ <br />^Approved bottled water. <br />O On-site hose bib that is <br /> Other (specify): <br /> <br />use: 0n^~_________ ___________ __I a^S^th" ^°f^bi®S?0?in^Ure hot and Mld “ng of potentially hazardous <br />the following hot temperature contm^tbe hot b^ng of ott potent^ b^ous foods above <br />E^amp stove □ Stemo & hotel trays <br />Rouble steamer Steam table & lids <br /> Elednc stove top Other (specify) <br />N°te: potentia,|y hazardous food Include- <br />ogetables, potato salad, eggs, and dairy products. <br />1868E. Hazelton Avenue | Stockton. California 952051 T 209 468-34201 F 209 4R4.ni ™ > <br />07/3/17 Page7of1i f 209 464-0138 | www.sjcehd.com <br />TEMP EVENT APP