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a�IN SAN .10AQUIN COUN1 ECOMD <br /> j ENVIRONMENTAL HEALTH DEPARTMENT <br /> •`� '� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> MAR 10 2017 <br /> cq��oR�P Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov eh� <br /> `-�IROIVMENTAL HEAL,jH <br /> PERMIT/SERVICES <br /> TEMPORARY EVENT APPLICATION <br /> To be completed and signed by E�Coordinat�r� then returned to the Environmental Health Department with all <br /> end of the Food or's Applicati ns no later than two weeks prior to event <br /> GENERAL EVENT FILE INFORMATION J <br /> 1. Name of Event: erYl�i� fit-I ��ci GSC!{ ��G�Gz U�Z Bre, OOrr*S-� <br /> 2. Date(s) of Event: tillarc h 5`, yf7 Time of Event: <br /> 3. Location: 1 1-7 14et7f J e- - %l 5.54Z � f <br /> 4. Event Coordinator(Name): rcz&/e� NI'td"O Telephone: (�cy) �169-C/ Ufa <br /> Mailing Address: TO Box <br /> 5. Number of Food Booths: �® -iif5 feet S�c1/(t� &-- uirla <br /> 6. Approximate attendance at peak time: /,SC_ Total Attendance: 0 Average Age: <br /> UTILITIES <br /> 1. Is potable water supplied and available for each food vendor: ❑ Yes ❑ No <br /> 2. Is electricity supplied and available for each food vendor: ❑ Yes ❑ No <br /> 3. Are janitorial facilities available: ❑ �j�,Yes ❑ No V <br /> L <br /> 4. Number of toilets provided: <br /> 5. Name of sanitary garbage disposal company: Number of dumpsters: <br /> 6. Method of disposal of liquid waste for food booths: <br /> APPLICATION <br /> 1. Submit the following to the Environmental Health Department two weeks prior to the event: <br /> a) Temporary Event Application <br /> b) Application Review Fee of$139 <br /> c) Temporary Food Vendors Applications for each booth <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 /> • $139 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 ($208.50 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 Coordinator: Date: <br /> r <br /> EHD 16-02 Page 1 of 11 TEMP EVENT APP <br /> nRm1/1R <br />