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Environmental Health Department <br />Date(s): "1. <br />2. <br />3. <br />4. <br />5. <br /> Other (specify): <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />SAN JOAQUIN <br />------COUNTY------- <br />GrcotnfSS grows hci'e. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />are required to return a signed and completed copy of this checklist to <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 />nt!?,,1®-02 page 7 of 11 TEMP EVENT APP <br />vI/ 0/ I / <br />LZ\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 />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 />All food vendors (both for profit and non-profit) <br />the festival coordinator three (3) weeks prior to this event. <br />I.Name of Event: <br />c/~- ^552(0 <br />Phone: I) Alternate: ( ) <br />List food to be sold or given to the public:) A r£)^/ F/CZ S <br />I am providing food that is NOT prepared at home: Yes O No <br />All food is prepared on-site or is from approved commercial facilities: jXYes No <br />Name of facility: C, I (Phone: ( ) <br />Address of facility: UjKttnd SSCTA fcrA ___________ <br />I am providing a booth with the following: (to p rot pit my unpackaged food and food-preparation areas from flies, <br />dust and the public) u <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />^4\pproved 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 usejX^Yes I""!' 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: Yes No <br />1 3m Prov'din9 the following hot temperature control for the hot holding of all potentially hazardous foods above <br />O Camp stove | | Sterno & hotel trays <br /> Double steamer -^Steam table & lids <br /> Electric stove top Other (specify) <br />The following is information about myorganization/business: <br />Name of orqanization/businessr —- <br />Address: 2-17.5 GIJifcvHr/T <br />rwT 4c2-?Z-^(