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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />Water supply dispenser with warm water at a minimum of 100T (i.e. 5-20 gallon container with spigot). <br />One separate tub (bucket or basin) for the collection of rinse/wastewater <br />|X] Paper towels and pump-style soap container <br />13 <br />"Important** <br />Completed by: 14. <br />Papvf Hand Tcwcts, <br />SoflC diSilwinMM <br />Cutarg Board <br />Ptupa’ic Sfuvc <br />7V~ <br /> 3 <br />Proparv© Tank. <br />ond Wate*FUtwj Vi'alo* <br />Fite Extmpjrtfwr <br />Ice Cooler <br />Owner <br />Title <br />S«p ir«d Waler <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />KI Three compartment sink. <br />Ste’FK) WChalTing <br />Dab <br />5 Gal Hand <br />Sanitre’ buckirt- <br />blaach & water Io* <br />Clcri’lU wn>l”p cto®»s <br />KI .Three deep tubs (basins 6-8 Inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />IX] Detergent, bleach, and wiping cloths (cleaning towels). <br />|X1 Tub to store wiping cloths in bleach solution. <br />Efctra <br />Wafitv <br />5-70 G* <br />Hind wiish WMeo <br />SAN JOAQUIN <br />------COUNTY------ <br />(......rt-T Greotnen grows here, <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45T (if food is used the following day. maintain below 41T temperature): <br />(Xi Ice chests Refrigerator <br /> Refrigerated truck Ice bath and tubs <br /> Other (specify)_ _ <br />Names of responsible persons to be’ present in booth during all hours of operation: <br />Guadalupe Jimenez-Ayala. Cristian C Donato, and Cynthia Jimenez-Ayala <br />Q2ZQ3Z21 <br />Date <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 throe weeks prior to <br />this event. <br />Signature <br />Ejrtm Sags & f-vod Contarwrs must bo | <br />Sftyoo’ 6 AXYie® off of Hw QrtXMKl' | <br />2 <br />Garbage <br />Can <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/'ehd <br />EHD 16-02 Page 8 Of 11 TEMP EVENT ARP <br />06'19.T9 <br />----------------------Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />] Health Permit [