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Environmental Health Department <br />1.1. Name of Event: <br />2. <br />Address: <br />Phone: <br />•3. <br />4, <br />5. <br />a <br /> On-site hose bib that Is connected to a potable water source. <br />9. <br />meats, tamales, cooked beans, rice, <br />TEW EVENT AFP <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, end dairy products. <br />pTStemo & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />7. <br />8. <br />1868 E. Hazelton Avenue | Stockton, California 95205 j T 209 468-34201 F 209 464-0138 | www.sjcehd.com <br />EHD1S42 PaoeToflt T™"™ <br />07/3/17 <br />SANJOAQUIN <br />-----COUNTY------ <br />Greatness grows here, <br />TEMPORARY FOOD VENDOR’S APPLICATION <br /> Other (specify): x ____________________________ <br />Electricity is provided tor my booth’s use: Yes No <br />I am providing an accurate probe thermometepto measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation>0Yes 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 /> Electric stove top <br />Data(s): 'fYWA <br />■I <br />>,.yj .. <br />I'h«ipo^'h <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 />(Mm <br />The follovwng Is Information about my organlzetfan/busfriess: <br />Name of organization/buslness: <br />HD ______ <br />( TO ) Alternate; ( ) <br />List food to be sold or given to the public ,(T)Y CjiPCAAj <br />I am providing food that is NOT prepared at homei^^es No <br />All food Is prepared on-site or Is from approved commercial faculties: tj^es No <br />Name of facility: Phone: (lyi) <br />Address of facflltyiZJ^ZISZ^— <br />I am providing a booth with the following: (to praters my unpackaged food and food-preparation areas from files, <br />dust and the public) <br /> A booth with walls end celling constructed of either wood, canvas, plastic, similar material and fine mesh Uy <br />screening, 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 />J/fSther (specify): W _________-_______________________—____ <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 />Approved water for drinking, utensil and hand washing will be provided In my booth by the followfag methode: <br /> Approved bottled water.