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9 <br /> S A N 10 A Q U f N Environmental Health Department <br /> COUNTY <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> All food vendors(both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br /> the festival coordinator three(3)weeks prior to this event. <br /> Date s - � <br /> 1. 1.Name of Event: �� t.C�(� � O�- <br /> 1 <br /> 2. The following is information about my organization/business: <br /> Name of organization/business: <br /> Address: l t oq 1i +' '•c1 `��5� <br /> Phone: ( '� ) �� -7� Alternate: ( ) <br /> 3. List food to be sold or given to the public: <br /> 4. 1 am providing food that is NOT prepared at home: ❑Yes L440 <br /> All food is prepared on-site or is from approved commercial facilities. �s❑ No <br /> Name of facility: Phone: ?'C, <br /> Address of facility: i "r <br /> 5. 1 am providing a booth with th following: (to protect my unpackaged food and food-preparation areas from flies. <br /> dust d the public) <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 /> ❑Other(specify): <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 bottled water. <br /> ❑On-site hose bib that is connected to a potable water source. <br /> 'B Other(specify): <br /> 7. Electricity is provided for my booth's LMei Yes❑ No <br /> 8. 1 am providing an accurate probe thermometV to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation: 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 ❑Stemo&hotel trays <br /> ❑ Double steamer Steam table&lids <br /> ❑ Electric stove top ❑ Other(specify) <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 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHU 16-02 Page 7 of 11 TEMP EVENT APP <br /> 0713117 <br />