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Environmental Health Department <br />10. <br />11. <br />OR <br />12 <br />13 <br />Completed by.14 <br />Paper Hand Towftts <br />Soap (hspenfiei <br />Cuftrnfl Board <br />Blanch <br />Propane Slnve <br />Propane tank <br />Bleach and WalerSoap tu rd W a tetr <br />j <br />Fir e Extirxiutshw <br />M <br />Q <br />Title <br />Exira <br />Waioi <br />5 Gal Hand wash <br />Watstewalrw Container <br />Sanibzer bucket <br />bleach A waiat for <br />storing wtprng ctotM <br />Booth must, be on <br />Concrete. Asphalt <br />Plywood, or a Tarp. <br />Garbage <br />Can <br />SAN IOAOuIN <br />• CM t N "’■ <br />r {/-y-j' <br />Signature <br />Names of responsible persons to be present in booth during all hours of operation: <br />__________________________V3 V-Wt C <■■.. tT 1 t.'. k - -. 5______________ _ <br />Rinse alar <br />.r^Paper towels and pump-style soap container <br />H.I Water supply dispenser with warm water at. a minimum of 10()°F (re 5-20 gallon container with spigot) <br />B.1 One separate tub (bucket or basin) tor the collection of rinse/wastewater <br />Ice Cooler.Jr <br />“Important <br />Cara in BUB’ * f'')od Contamnra mii.ia fio <br />siw»</« »>a» ■’»" °> r*18 vmm^ . <br />H' ThmtrcotrHiartn k>,emS W'th'n my boo,h for ,he sanitary cleaning of food preparation utensil <br />0„Tfiree deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution tone tablespoon of bleach per gallon of water) <br />Detergent, bleach, and wiping cloths (cleaning towels). <br />UzkTub to store wiping cloths in bleach solution <br />All food vendor booths are subject to inspection. Please make a copy of this application in <br />preparation for this event. A copy of this checklist must be in the booth at all hours of <br />preparation and operation Return original to festival coordinator three weeks prior to <br />this event. <br />I Stetrn) <br />DlsJi <br />^"3 is ™ta“^°r4rF^S)0' P0,<in'ia”y ,,azardous ,“’d5 <br />®,Cechests □Refrigerator <br />H Refrigerated truck Q |ce bath and tubs <br />[■] Other (specify) <br />Health Permit <br />l am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />I’00111 <br />. —--------------- ' ■ ................... <br />1868 F Hazelton Avenue | Stockton California 95205J 1^209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />‘ .c- MAn r i/ - t vV/ <br />5 20 Gal <br />v~ Hand wauih WmIoj <br />A