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r . <br /> S A N J O A Q U I N Environmental Health Department <br /> TEMPORARY FOOD VENDOR'S APPLICATION <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 I ,/ <br /> k(s): /[y <br /> 1. 1.Name of Event: <br /> 2. The following is information about m organization/business: <br /> Name of organizaUon/business CiLL4� <br /> Address: t r 1�1 F <br /> Phone: ) 1 �i. Alternate: <br /> 3. List food to be sold or given to the public: <br /> 4. 1 am providing food that is NOT prepared at home: S Yes ❑ No <br /> All food is prepared on-site or is from �approv commercial facilities: Yes No <br /> Name of facility: � l � � Phone <br /> Address of facility: ' VY� t' t C <br /> 5. 1 am providing a booth with the following: (to protect my un ckaged f an food-prepar tion areas from flies, <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 /> 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 /> are from the public. <br /> Other(specify): <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 /> 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> El Approved bottled water. <br /> ❑ On-site hose bib that is connected to a potable water source. <br /> ❑ Other(specify): 11-11 <br /> 7. Electricity is provided for my booth's use es❑ No <br /> 8. 1 am providing an accurate probe thermorri to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation: ff Yes ❑ No <br /> 9. 1 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 �Wa <br /> table 8�lids <br /> ElElectric stove top (specrfy) ,,`�"�" �( , <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked lam. rice, <br /> vegetables,potato salad,eggs, and dairy products. <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 q64-013g an,yr sjgpv org/Qt� <br /> E H0 16 qz <br /> 06/2912023 Page 7 of 11 TEMP EVWJT <br />