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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1 Name of Event1 Date(s) <br />2 <br />Address <br />Phone <br />3 <br />4 <br />5 <br />m3 i-oui; <br />Approved water for dnnking. utensil and hand washing will be provided in my booth by the following methods6 <br /> Approved bottled water. <br />9 <br />7 <br />8 <br />j-------------------------------- <br />Note. The only operations not required to piuvide enclosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources <br /> Stemo & hotel trays <br /> Steam table & lids <br />Sf Other (specify) Tor <br />meats, tamales, cooked beans, rice, <br /> A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas It will also have a smooth and cleanable floor (concrete <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public <br />31 Other (specify) \ f <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Alternate (^a 9 ) - C7 2 <br />SixJQvJ C e ______ <br />1868 E Hazelton Avenue | Stockton California 85205 | T 209 468-3420) F 209 464-0138 | www sjgov org ehd <br />f HO’6-02 Paye? olll TEMP EVENT APP <br />0®1»19 <br /> On-site hose bib that is connected to a potable water source <br />pother (specify) foot) Trvofc- 'ils (}f ftAccblx <br />Electricity is provided for my booth’s use Ej Yes No r- ^1 <br />I am providing an accurate probe thermomejer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation 0 Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135”F <br /> Camp stove <br /> Double steamer <br /> Electnc stove top <br />All food vendors (both for profit and non-profit) are required Io return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event <br />I ioH Si_________ <br />The following is information about my organizalion/busmess <br />Name of orgamzation/busmess \Jc< 1 p4 Jckr) <br />I'VOUG? nJ- JcacL- '(oc*C- - <br />(2*5) 7/Z qW7________ <br />List food to be sold or given to the pubhc GUvrrb S f <br />I am providing food that is NOT prepared at home Yes Ej No <br />All food is prepared on-site or is from approved commercial facilities: F3 Yes No <br />Name of facility Lfl GmiSgrifl lAMj <? 5 t g Phone. (7^*9) 3(oL9 3 <br />Address of facility 1 (I S 6 A <br />I am providing a booth with the following (to protect my unpackaged food and food-preparation areas from flies <br />dust and the public)