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2. <br />Phone: <br />3. <br />4. <br />73/ ^^9 <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />EHD WO2 <br />07/3/17 <br />7. <br />8. <br />Environmental Health Department <br />J <br />Note: Examples of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br />SANJOAOUIN <br />-----COUNTY-—- <br />Greotnes* grow, here <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1. <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 following methods: <br />® Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br /> Other (specify): ___ <br />Electricity is provided for my booth's use: Yes £&No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hayarrinns <br />foods during all times of booth operation: 0 Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135T: <br /> Camp stove O Sterno & hotel trays <br />Double steamer Steam table & lids <br /> Electric stove top Other (specify) <br />1868 E Hazelton Avenue | Stockton, California 952051 T 209 468-34201 F 209 464-0138 | www.sicehd.com <br />Page 7 of 11 TEMP EVENT APP <br />. are required to return a signed and completed copy of this checklist to <br />weeks prior to this event. <br />1 Name of Event K) Kt .Date(s): <br />The Mowing Is info^fe Wm^U^fesi^6 7 <br />Name of onganization/business: ______________________________ <br />CO/OH/ C & ^53 <br />) ..7 J— Alternate:! )_ <br />List food to be sold or given to the public: /'Ex C-h K.j 0 S <br />. P) Ce z AJa <WP'* <br />I am providing food that is NOT prepared at home: ® Yes No <br />All food is prepared on-site or is from approved commercial facilities: ^9 Yes No <br />Name of facility. M Tndt <4/? Phone: (<(t)) <br />Address of facility: /^-^Q \aJ CVlCf^y P-d H ^or« (f^ <br />1 'dust™3 tb|Ot)1 W*th ,he (t0 Protect my unpackaged food and food-preparation areas from flies, <br />(2^ 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 />D Other (specify):____________________________________________ <br />■ ■: ® . <br />zY ■ " ■ ■ - ■ <br /> ' ■ <