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Environmental Health Department <br />Date(«): Jt-fI.Name of Event <br />2. <br />•3. <br />4. <br />5. <br />6. <br />I <br />8. <br />meets, tamales, cooked beans, rica. <br />regal <br />i <br />i <br />I4.f (4<m GrVksk4r> n____________________ _ <br />Afraw/j CIBL/kJ CiQ QStM'Tl <br />AltemaiK(^0^) ^5?o ~/3>0$______ <br />i! <br />i <br />SANJOAQUIN <br />-----COUNTY— <br />Graotne** grow here> <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />■: <br />7. <br />8. <br />1888 E Hazelton Avenue | Stockton, CaUfornie 852051 T 208 488-34201 F 209484-0138 | wwv.»k»hdxom <br />gjO lfrOZ P»O»7of11 TEMP EVENT APF <br />waf\7 <br />PA toad vendors (both for profit and non-profit) are required to return a signed and completed copy of this oheddist to <br />the fesfival coordinator three (3) weeks prior to Site event <br />1. I.Nameof Event o£ QK- <br />The foBowfog Is Information about my o^anizafton/buslness: <br />Name of orbantzationfouslness: <br />Addrees: <br />Hwre: _______ Aftamate:(<0^) __ <br />Ust food to be add or given to the puhfic:. &HTty\s OA/id^Cr^ps <br />I am providing food that Is NOT prepared at home: |3 Yes No <br />AH food Is prepared on-site or Is from approved cammerdel taciitieK E Yes No <br />Name of fectKy: lVi'.(47rf\ ^JtJfehrYX _____Phons: <br />Address of fedinyL^a .SIS /-<-rrWl^ SfocJ^Trm /ftft <br />I am providing a booth with the following: (to protect my unpadcaged food and food-p re paraSwi areas from ffies, <br />dust aid the publlo) <br /> A tooth with walls and cefllng constructed of altar wood, canvas, piastta, slndtar matafal end line mesh fly <br />screening, completely endosing open food areas. It wll also have a amooth and deanabte floor (concrete, <br />asphtet, oiean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the pubito <br />JZfOther fspecftA; W ___________________________________ <br />Noto: The only operations not required to provide endosod tenths are those which eell beverages from <br />approved dispensers, or prepackaged foods from approved sounres. <br />Approved water for drinkino, utensil and hand weahino wtl be provided in my booth by the foEovring metads: <br /> Approved touted water. <br /> On-site hose bfc that Is connected to a potable water source. <br /> other (specfly): <br />Electricity Is provided for my booth’s uae^EI Yes No <br />I am providhg an accurate probe ftwmometer to measure the hot and cold holding of potentially hazardous <br />foods during all flmes of boothoperaitonjPYes d No <br />I am providing the fofioMlng hot temperature control for the hot hoi ding of all potertialy hazardous foods above <br />136*F: /• <br /> CampMove J3atemo&hotel traya <br /> Doubtesteamer Steam tabla Afote <br /> Etectric stove top Other (specify) <br />Note: Bramptes of potentially hazardous food Inelude: <br />vsgtaabloo, potato sated, eggs, and dairy products. <br />>•..; : S. <br />^V.ypyy^’