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Datefs): <br />4. <br />9. <br />SAN JOAQUIN COUNTY <br />ENVIORMENTAL HEALTH DEPART^--N- <br />1868 East Hazelton Avenue, Stockton, California <br />(209) 468-3420 <br />otablc watccsourco- /_ <br />1g of all potentially hazardous foods <br />[ ) Electric stove top <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy <br />Checklist tv thv fcStiVal CGvrdiuutvF three (u) iVCCko piivi iv uiiS CVvuu <br />1. Name of Event: __ __________ <br />2. The following i<lnformation about my organization/business: <br /> Name «forgeniz-tinn/busiuw; ; /--------->27 <br />Address: K (V ’ 7^------ <br />Phone: A!ten«to/ <br />3. List footHo be Sold orRiven to the public: /P 4zX>H<tM/Zi7 . Zf^rA <£*66-^ <br />I am providing food tKat is^OT prepared at home: [kfYes7 ( ] No <br />Ail food is prepared on-site or is from approved commercial facilities: res [ jNo <br />Name of facility: M - - ? Phone: (h_^ & ) 2 % 2. <br />Address ot Facility: /*?- O : <br />5. Jam providing a booth with the following: (to protect my unpackaged food and food-preparation areas from <br />flies, dust and tire public) <br />[ ] A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine <br />mesh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor <br />(concrete, asphalt, clean tarps and smooth wood arc acceptable) and constructed to separate food and food <br />preparation areas from the public. ✓ z , <br />Other (specify): > 4 C6 C / , f <br />Note: The only operations n^t required to provide enclosed booths are those which sfcU bcLef^gcs from <br />approved dispensers, or prepackaged foods from approved sources. <br />6. Approved water for drinking, utensil and hand washing will be provided in my booth by the following <br />methods: ® <br />( ] Approved bottled water. <br />[ ] On-site hose bib that is connected to a potable watci <br />y) Other (specify): X' <br />7. Electricity is provided for my booth's use: <br />8. 1 am providing an accurate probe thermometer to measure the hot <br />foods during all time of booth operation: |/| Yes [ <br />1 am providing the following hot temperature control for the hot holdin <br />above 135 degrees Fahrenheit: <br />[ ] Camp Stove [ ] Double steamer <br />[ ] Stemo & hotel trays [ ] Steam table & lids <br />Note: Examples of potentially hazardous food include: <br />potato salad, eggs and dairy products.