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Environmental Health Department <br />Gr <br />All food vendors (both for profit and non profit) are required to return a signed and completed copy of this checklist to <br />i. <br />2. <br />Phone:) <br />ri pn a3.List food to be sold or given to the public: <br />5. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods:6. <br /> Approved bottled water. <br />9. <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APP <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 />7. <br />8. <br />ISS’F: <br /> Camp stove <br />Double steamer <br />vPT Electric stove top <br />Name of facility: <br />Address of facility:_______________________ <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />Name of organization/business: <br />Address: <br />SAN JOAQUIN <br />— COUNTY <br />>• (< r -. f ■ t <br />TEMPORARY FOOD VENDOR’S APPLICATION <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 />J^fother (specify): FoO <1 ry clc,____________________________________________ ______ <br />, Dublin <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page 7 of 11 TE“." E'.'E?." <br />07/3/17 <br />Hi <br />_ Date(s): [)c.£ / <br />I am providing food that is NOT prepared at home^fYes No <br />All food is prepared on-site or is from approved commercial facilities: O Yes No <br />All feparl prPJIfvtV// bgAflcPhone:(___1 <br /> On-site hose bib that is connected to a potable water source. <br />Other (specify): pop 3 ruck .b[ <br />Electricity is provided for my booth’s usei0 Yes O No <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: Qi es EJ No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br /> Stemo & hotel trays <br />vO'Steam table & lids <br />V0Other (specify) <br />V > UrxAA- <br />(5’* ) ^70 - ’XQ1* <br />the festival coordinator three (3) weeks prior to this event. <br />1 Name of Event: C |k ri <1 maJ In ihf <br />The following is Information about my organization/business: <br />rotlA'inJ MojhL <br />PnlkuirtV <br />__ Alternate: ( <br />AHhjIliiL