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Environmental Health Department <br />1.I.Name of Event: <br />2. <br />Address: <br />3. <br />4. <br />5. <br />8. <br /> Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />9. <br />meats* tamales, cooked beans, rice, <br />TEMP EVE KTAPPP*S«7cr11 <br />lOi <br />r St, t^VWhCA <br />)_______ <br />Cm) <br />7. <br />8. <br />Note: Examples of potentially hazardous food Include; <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenue I Stockton, California 85205 T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EH01 M2 Plfil 7 «rf 11 TE\" E'.'E.'T! <br />07/3/17 <br />Date(s): W <br />AH 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 />(\F <br />The following Is Information about my organlzatlon/buslness; <br />Name of organlzatlon/buslness: <br />7^ fc:r; <br />Phone: Alternate: ( <br />List food to be sold or given to the public; FtlK ~Afe. <br />I am providing food feat is NOT prepared at homef^lVes No <br />All food is prepared on-slte or Is from approved commercial fad!lties:X^DYes No <br />Name of facility: Phone: (?(f|) ~ --------------------- <br />Addrees of facility: Vkb St ----------------------- <br />I am providing a booth with the following: (to protect my unpackaged rood and food-preparation areas from files, <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 />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 /> (^bther (specify): flQ ____________________ <br />Note: The only operatians not required to provide enclosed booths are those which sell beverages 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 />Electricity^^p^ded for my booth’s <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation:'^/ Yes No <br />I am providing the following hot temperature control tor the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove JZlStemo & hotel trays <br /> Double steamer Steam table & lids <br /> Bectric stove top □Other (specify) <br />v SANJOAQUIN <br />-----COUNTY------ <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />.Y' 7 ■ t;