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10. <br />11. <br />OR <br />12. <br />utensil wash within my <br />13. <br />14.Completed by; <br />Signature <br />Health Permit <br />Paper Hand Tcivefcj Soap dispenser j <br />Bleach <br /> <br />J2Propane Tank <br />Fire Extinguisher <br />Page s of 11 TEMP EV&NTAPP <br />EHD 16-02 <br />7/2 87 W <br /> <br /> <br />ExLi3 ice Bags & Food Containers mjsl be <br />stored 6 fncbes orfort/ie ground! <br />5 Gal Hand wash <br />Wastewater Container <br />5-20 GaL <br />Hand wash Water <br />Extra <br />Water <br />j Cutting Board j <br />Propane Stove <br />soapy °"e antl one for a <br />©Detergent, bleach, and wiping cloths (cleaning towels). <br />jQ'Tub to store wiping cloths in bleach solution. <br />feditsssssi z <br />[Xy/Vater supply dispenser with warm water at a minimum of 100’F (i.e. 5-20 gallon container with spigot). <br />L^Qne separate tub (bucket or basin) for the collection of rinse/wastewater. <br />QTaper towels and pump-sfyie soap container. <br />A t0 during a’1 hours of operation: <br />Q>6/Znpyv <br />Title <br />Siemow/Chaffing <br />Dish <br />SanHizwbuckal- <br />HeachA waterier <br />storing wiping ctoths <br />A-H <br />Ice Cooler"]^ <br />reiATVyu * j; rjfSQ —jT] <br />Lflllproviding the foI(ow'n9 for adequate hand washing facilities, but separate from <br />Dooin. <br />.....SSSSSSE-gESi <br />Boolh must be on <br />Concrete, Asphalt, <br />Plywood, or a Taro. <br />~ —----------------— <br />d <br />Garbage <br />Can <br />Soap and Water Rinse Water <br />□ Ice chests [j Refrigerator <br />D Refrigerated truck O Ice bath and tubs <br />Other (specify) r Z7 cp ________ ____ <br />l am providing the following items within my booth for the sanitary cleaning of food preparation utensils: <br />Er^Three compartment sink.