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�01a <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> � EtvTAL HEALTH Telephone: (209) 468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> p��lJIITISERVICES <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 iNFORWIATiOni 1 <br /> 1. Name of Event: esa r �d ye Z -B1'ea-k-4 <br /> rrs T <br /> 2. Date(s) of Event: Time of Event: 2- <br /> 3. Location: <br /> n/� Z <br /> 4. Event Coordinator(Name): 0- Imzd IG Mi2d b 1 d Telephone: (�j) 'Flo q- 17306 <br /> Mailing Address: 3 a )? Way. 040C , 4 Gl Sa 9 <br /> 5. Number of Food Booths: N6 boa f t, — 6uge t S'ef l e- se_ry r y)q <br /> 6. Approximate attendance at peak time: 50 Total Attendance: / 4 O 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: ❑ Yes ❑ No 700 - � C <br /> 4. Number of toilets provided: T�U'f °� <br /> 5. Name of sanitary garbage disposal company: Number of mpsters: <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 NU G-08 •���)�� D �'��ZQ <br /> c) Temporary Food Vendors Applications for each booth �EZ/v= Q!- l so 7( 48� <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 /> e 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 emporary event coordinator, I am responsible for meeting California State <br /> standards and the Env -mental Health Department policies and procedures. <br /> Event Coordinator. Q� Date: J-;2 6 "1 <br /> EHD 16-02 Page 1 of 11 TEMP EVENT APP <br /> —1—i4a <br />