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ji <br />Environmental Health Department <br />( <br />1 <br />a <br />5. <br />6. <br />9. <br />nwcte, tamale*, cooked bean*, rice, <br />1. <br />8. <br />i <br />Atemate: ( <br />K4a <br />1M8E Hazelton Avenue | Stockton. CaWomfa 952051 T 209 468-34201 F 209 484-0138 | www.sjcehd.com <br />PW.70H1 TEMPl^S<tm> <br />) <br />SAN40AQBIN <br />COUNTY----- <br />A.>tnei» $rawt hurt <br />TEUPORARY FOOD VENDOR'S APPLICATION <br />am fB<»ulred to raton) “XMInator three (3) week* prior to thte event <br />1 1 •Nm* * event -CArisAr^n s <br />2- The folowing i* information atxjut <br />E <br />a signed and completed copy of this checMat to <br />_f^k <br />my organlzation/business: <br />N«tooforgamzatioMxmines.:TT^ t Og <br />Mant* 2.^!—5 pc y<S>____ <br />Phooe: ____________ <br />Us* food to be sold or givan to the Dubec.-"^7z>s 6urri <br />I am providing foot that« HQI prepared at home: 0Ves No <br />AM food is preparedon-slteor is from approved commercial fecSties: B'Ye* No <br />Name of feciiity: Pd* phone: y ) 5^5-65 ^-9 <br />Address offecfflty:^fl£7 lapek^ sA C/4 ________ <br />' P"*** "V unpactagedfood andfoo<Hxeparat)on areas fromffiS? <br />B^A booth with wafc and ceBng constructed of either wood, canvas, plastic, simiar material and fine mesh fly <br />screening, completely endosfry open food areas. It w« also have a smooth and deenabte floor (concrete, <br />•sphafi, ctem tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />otbm from the piMc. <br />O Other (specify): _____ ____ <br />Note: The only operations not required to provide enclosed booths are those which sefi beverages from <br />approved dispensera, or prepackaged tbods from approved sources. <br />Approved water for drinking, utensfl and hand washing wffl be provided in my booth by the foObwmg methods: <br />Q^ppraved bottled water. <br />O On-site hose bfo that is connected to a potable water source. <br /> Other (specify): z ' <br />Electricity is provided for my booth's use: fS’Yes O No ' ' “' <br />I am preMding an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during aO times of booth operation: QYe* No <br />I am providing the following hot temperature control for the hot holding of aO potentially hazardous foods above <br />1^5*F: <br /> Camp stove □StemoA hotel tray* <br />STtouble steamer Steam tabte & fids <br /> Electric stove top Other (speedy) <br />Note: Examples of potentiatiy hazardous food Include: <br />vegetable*, potato sated, eggs, and dairy product*.