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-d <br /> S A N J O A Q U I N Environmental Health Department <br /> TEMPORARY FOOD VENDOR'S APPLICATIOR <br /> All food vendors (both for profit an non-pro <br /> npr t) are to th s requirequired to return a signed and completed copy of this checklist to <br /> the fesfrvaf cooralnafor three r:3J prior�-}Ir� s�, 9 _7- <br /> 1 t Name of Event:�ep I wr " !!"—�� J� Date(s) f� <br /> z The following is information about my organizationfbusiness: <br /> Name of organizationlbusiness: l4 ���R t� '�" Iti✓r <br /> Address: <br /> Phone: 3u� 113 S-0 Alternate' ( Sv )_ 3C,t( - 7yU3 <br /> 3 List food to be sold or given to the public: <br /> N,,,,,, L�n,ca UT_5 <br /> 4. 1 am providing food that is NOT prepared at home.Yes❑ No <br /> All food is prepared on-site or is from approved commercial facitibe s- ❑Yes ❑ No <br /> Name cf taC&ty-. i <br /> Address of facility. <br /> 5. 1 am providing a booth with the following: (to protect my unpackage-d food and food-preparation areas from flies, <br /> dust and the public) <br /> A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br /> k)eening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br /> asphalt, dean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br /> areas from the public. <br /> ❑Othef(spay): <br /> Note: The only operations not required to provide enclosed booths are those which sell beverages from <br /> approved dispensers, or prepackaged foods from approved sources. <br /> 6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Approved botfled water. <br /> ❑ On-site hose bib that is connected to a potable water source. <br /> ❑Other(specify) <br /> 7. Electricity is provided for my booth's use:�Rj Yes❑ No (,ery w tF S <br /> 8. t aM 713144r G at%arrw:at& Va4e thRzmrwR1ru tta mi . v ve tbR Mn4t.avri cakd tudriurv;of pratievkQJJy b=zardrau% <br /> foods during all times of booth operation:0 Yes❑ No <br /> 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> 135°F: <br /> ❑Camp stove ❑ Sterna,&hotel trays <br /> ❑ Double steamer ❑ Steam table& lids �1 I r� �p!? C., rj <br /> ❑ Electric stove top ❑ Other(specify) A) <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcetid.com <br /> EHUI 1 -02 Page 7 of 1 i <br /> 07WI TEMP EVENTAPP <br />