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2. <br />r a <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />Environmental Health Department <br />I am providing food that is NO j prepared at home: @ Yes Q No <br />All food is prepared on-site or is from approved commercial facilities: 0 Yes Me <br />Name of facility: ____________ ________________________Phone: ' <br />Address of facility: <br />1 adusPt and jhe pSP f°"0Win9; Pr°teCt my unPacka9ed food a"d food-preparation areas from files, <br />0. A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh flv <br />screening completely enclosing open food areas, it will also have a smooth and cleanable floor {concrete <br />aSfromTe pSc3^ W0°d aCCeptabie) and constructed to separate food and food preparation <br />0 Other (specify): <br />A C c- g a <br />£ \ <br />\j > <br />. Alternate: ( 2 ) <br />=>2HaZSlt°r' *’*« ' Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sicehd com <br />07/3717 Page 7 or 11 TEMP EVENT APR <br />Date(s): _ <br />L 2 2Z <br /><7 C 7) <T y f 2 2 2_______ <br />List food to be sold or given to the public: /G 77 ( f <br />SAN JOAQUIN <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />2 ,0 re,urn a si9ned and rompleted to <br />1. 1. Name of Event: Y C tf & ■(' T ry-—y --------1---------------------- <br />I he following is information about my organization/business: <br />Name of organization/business: /'T, /Zy/4/< <br />Address: 7 6 n. t 7 7 2 /''./S U-’/l <br />Note: The only operations not required to provide enclosed booths are those which sell beveraoes from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Approved bottled water. <br />O On-site hose bib that is connected to a potable water source. <br /><3 Other (specify): t-i CUirg p &~T' <br /> Electricity is provided for my booth’s use: 0 Yes 0 No —————----------------—---------------- <br />I am providing an accurate probe thermometer to measure the hot and cold hoiriinn nf nntam+ioii, a <br />foods during all times of booth operation: O Yes O Mo t / J 9 °f potentia,|y hazardous <br />1 prF0V,d,ng the fol,owin9 hot temperature control for the hot holding of all potentially hazardous foods above <br />01 Camp stove 0 Sterno & hotel trays <br />0 Double steamer 0 steam table & lids <br />0 Electric stove top 0 other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Z2-