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�. SAN .10AQUIN COUNTY <br /> F ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �¢Ci k pRN�P <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.orq/ehd <br /> TEMPORARY EVENT APPLICATION <br /> To be completed and signed by Event Coordinator, then returned to the Environmental Health Department with all <br /> of the Food Vendor's Applications no later than two weeks prior to event <br /> GENERAL EVENT FILE INFORMATION <br /> 1. Name of Event: 4ir-i t <br /> 2. Date(s) ofEvent: DQ t�.l Time of Event: to a i n'1 l 2 Dr <br /> .� — <br /> 3. Location: U'7tCh1t]6 Klt%tr��2 12S 5: 4CC&;1015 Uzi;zi; CA • �1 s:N0 <br /> 4. Event Coordinator(Name):,%,96U'11'lR, Telephone: 12CA a0_-;L <br /> Mailing Address: R d, 8t)y 135,9 L <br /> 5. Number of Food Booths: ( t nrowe_ fipaszko- <br /> 6. Approximate attendance at peak time:'6DCTotal Attendance: Average Age:• li I' 5 <br /> UTILITIES <br /> 1. Is potable water supplied and available for each food vendor: SYes ❑ No <br /> 2. Is electricity supplied and available for each food vendor: ❑ Yes ❑ No <br /> 3. Are janitorial facilities available: E V�es ❑ No <br /> 4. Number of toilets provided: P5 m r), 0 w,t►V e✓1 t-.,+ZE <br /> 5. Name of sanitary garbage disposal company:WaSe Ynawlt4W1QVl-'f" Number of dumpsters: <br /> 6. Method of disposal of liquid waste for food booths: SE I f C'mr +Ztl fLQ' O <br /> APPLICATION o <br /> 2p15 <br /> 1. Submit the following to the Environmental Health Department two weeks prior to the ever�l�G <br /> a) Temporary Event Application NMEN�v�CE� <br /> b) Application Review Fee of$130 ENi�4M��ISER <br /> c) Temporary Food Vendors Applications for each booth QE <br /> d) Temporary Event Site Plan <br /> e) Food Vendor List <br /> 2. If the event is selected for inspection, the Event Coordinator will be billed for inspection time: <br /> • $130 per hour(weekdays 8:00 am to 5:00 pm) <br /> • After regular business hours (weekday, weekends and holidays)the inspection is charged at the <br /> hourly rate, calculated at one and one half times ($195.00 per hour) <br /> This application is to be completed and signed by the Event Coordinator, then returned to the <br /> Environmental Health Department with all Food Vendor's Applications no later than two weeks prior to the <br /> event. <br /> I understand that as a temporary event coordinator, I am responsible for meeting California State <br /> standards and the Environmental Health Department policies and procedures. <br /> Event Coordinato : �; Date: _f <br /> Gun ia_n) Dann 1 nF 1 TFRAD CA/FAIT ADD <br />