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SAN JOAQUIN Environmental Health Department <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors(both for prord and non-profit)are required to return a signed and completed copy of this checklist to <br /> the fesbval coord"lor three(3)weeks prkn to th' vent <br /> 1, 1.Name of Event: <br /> 2. The following Is Information abr3trt my prgaruZation�tyugineSS <br /> Name of natirxvbusiness: '�' ! `t <br /> Address: r 1 9 <br /> r f_1• r IC <br /> Phone: Ap + Vf Aljernate: ( �`�/ I U�` r 5 <br /> tr jT <br /> 3 List food to be sold or given to the public: T, <br /> 4. I am provoing food that is DW prepared ad home: Ct-Yes❑No <br /> An food is prepared on-site or is from approved commercial faciMies: es No <br /> Name of facility: ffffff Pam:{ 7 <br /> Address of facility: <br /> 5 1 am proves a booth with the following: (to protect my unpackaged food and food-preparatlon areas from ries. <br /> dust and the public) <br /> A booth with walls and ceiling constructed of either wood,canvas, plastic,similar material and fine mesh Fly <br /> a r►drg, completely enclosing open rood areas It will also have a smooth and cleanable floor (oorwxete, <br /> asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br /> areas from the public. <br /> ❑Other jspecrfy): <br /> Note: The only operations not required to provide emlosed booths are those which sell beverages from <br /> approved dispensers,or prepackaged foods from approved sources <br /> 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the follorwing methods <br /> +110i5FOWed bottled water. <br /> ❑On-slue hose bib that is connected to a potable wager source. <br /> ❑Other(specify) <br /> 7. Electricity Is provided for my booth's use.JEJ44s C3 No <br /> 6. 1 am providing an accurate probe trwmameter to measure the hat and told holding of potentially hazardous <br /> foods during all times of booth operation, Yes❑No <br /> 9. 1 am providing the following hot teimperatu for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> 11 Camp stove t—s-1-emo&hotel trays <br /> ❑ Double steamer ❑Steam table&lids <br /> ❑ Electric stove top ­F her(specify) <br /> Note: Examples of potentially hazardous food include; meats, tamales, cooked berm, rice, <br /> vegetables, potato salad, eggs,and dairy products. <br /> M;6 E. Hazelton Avenue I Stockton ti.abaorr.a 9$2n-5 i T 2)9 469 F 2,09 464-i:t 2.E wo wv si!-ov org'e" <br /> EHD 16-02 TEMP EVENT APP <br /> 4G2B2U23 <br />