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■I <br />Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Date(s):1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />Other (specify): <br />6.Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />O Approved bottled water.!■* <br />O On-site hose bib that is connected to a potable water source. <br />1 <br />9. <br />S meats, tamales, cooked beans, rice, <br />Scanned with CamScanner <br />7. <br />8. <br />1868 E. Hazelton Avenue | Stockion. California 95205 | T 209 468-3420 | F 209 464-0138 | www.Sjcehd.com <br />EHO IS-O? Pag. 7 of 11 TEMP EVENT APP <br />07/3/17 <br /> Stemo & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />SAN JOAQUIN <br />r OUM7 Y <br />c>( <br />Note: Examples of potentially hazardous food include: <br />vegetables, jMrtato salad, eggs, and dairy products. <br />O A booth with wals 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 />areas from the public. <br />Note: The only operations not required to provide enclosed booths are those which sen beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />See \C\C_.________ <br />(5?L^\)^ri U Alternate: ( 7Ch) 5^ <br />List food to be sold or given to the publicf\~>( e k.x { i <br />I am providing food that is NOT prepared at home:^Yes Q No <br />Al food is prepared on-site or is from approved commercial facilities:^ Yes No <br />Name of facility: 1 JC/yive l/Y. Phone: (7^°l)5iZ~> f I ____ <br />Address of fadljty: ~IV/(L P7\Vr> 7^-5^ <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />IAk_L <br />The following is information about my organization/business: <br />Name of organization/business:, <br />5\u\<\ ftue. <br /> Other (specify): <br />Electricity is provided for my booth's use: O Yes E No <br />I am providing an accurate probe thermometer ro measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Yes No <br />I am providing the following hot temperature control for the hot holding of al potentially hazardous foods above <br />135’F: <br /> Camp stove <br />Q Double steamer <br /> Electric stove top <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. . <br />I.Name of Event: V* ufr Cf jM.A'Xaj tx, V fAV V Date(s): \