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r <br /> SAN _JOAQUIN Environmental Health Department <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> An foOQ vcrn4xs(both tvi proll and rrou-prvlft)are rrquiied to relurn a sxrnekl anki conapleied cgpy of the Cflw3liSt to <br /> ttx fostivnl coordinator orret•(3)Nveeks"to this event. <br /> 1.Name.of Evert ��Q� uk_a4A - v oaten) a � � <br /> 2 The following is intormation about my organizaGnnl�b�usiness:!� <br /> Name of organ¢aixnnrbusiness &t�Gi l5 t �.i�� <br /> Address rL <br /> a M�tiC e. lA -� <br /> Pho»e. '75-- ;,7 L c Aftemate: <br /> 3 List food to be sold or given to the puhiic r �rY47 Y kt- r�A' r.3.S <br /> d'rr•.. 13v 1'r tv, e i r'r'+A <br /> 4 f am providing food that is NOT prepared at home-❑Yes U�Nc <br /> All food is prepared on-site or is from approved comme(Cial facilities:fX Yes[]No <br /> Name of facility: Phone f 1 <br /> Addrn_ss of facility <br /> 5. 12m, providing a booth with the following (to protect my unpackaged food and food-preparation areas from fifes, <br /> dust and the public) <br /> •y booth with walls and ceffing constructed of either wood.canvas plastic,similar material and fine Tnesh tty <br /> scmeening. completely enclosing open food areas. h wil! also have a smooth and cleanable floor ;concrete <br /> asPnalt, clean tarps and smooth wood are acceptable)and constructed to separate rood and food praVar-_':'on <br /> areas from+.he public <br /> C Other(specify): <br /> Note: The only operations not required to provide enclosed booths are those which sell beverages `rasa <br /> approved dispensers,or prepackaged foods from approved sources. <br /> 9 Approved water for drinking,utensil and hand washing will be provided in my booth by the following Metr003: <br /> ZApproved bottled water. <br /> ❑�Orr-site hose bib that is connected to a potable water source. <br /> El Other(specify): <br /> 7. Efecttieity is provided for my booth's use:Lj Yes LdNo <br /> 8 1 am providing an accurate probe therrimmeger to measure the hot and cold holding of potentially hazardous <br /> foods during ao times of booth oPr:ratfon Yes❑No polenbaity hazardous fords above <br /> 9 1 am providing the fonowing hot temperature control for the hot holditlg of all <br /> 135yF. <br /> ❑ <br /> El camp stave Sterno&hots[(rays <br /> /[Double steamer ,,a[,/steam table&lids <br /> El ectric stove top f. Othef(specfy) R f ' i-t <br /> q (A"A <br /> Note: Examples of potentially hazardous food include: meats, tatnwW . coolkod ins. fkt- <br /> vegetables,potato salad,eggs,and dairy products_ <br /> t858 E.Nazelton Avenue ; Stucktoit.C:attlonna 95?o? I T 239 468 3410 I F 2W 464-0138 ; W%VW$�>�d <br /> EM%m P40 7 d 11 <br /> 4GrL4'202.3 <br /> S <br />