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Environmental Health Department <br />1. <br />2. <br />Phone: <br />3. <br />4. <br />areas from flies,5. <br />6 <br />9. <br />meats, tamales, cootced beans, rice, <br />7. <br />8. <br />Ail food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. t <br />1-Nameof Event:^^^K-;>,^■^^<-^,'' <br />1868 E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />EHD 16^02 <br />Z'r n tttiCi <br />SAN JOAQUIN <br />COU N TY <br />G ei tocis ij/Qivs hen’ <br />TEO^IPO^A^Y FOOO VEMTOTO APPHCATOM <br />Q Other (specify): <br />^pSding0^^cSrdte p^te ftSioiJfc?,0™B“ure the and ho,d'n9 of P°tentia,,y ha*af<tous <br />I amproviding Se'foSn^hoften^ratur^jntrolfor the hot holding of all potentially hazardous foods above <br />135’F:B^tamp stove Stemo & hotel trays <br />Q Double steamer ^Steam table & lids <br /> Electric stove top Other (specify) <br />Mo?®- Enampteo of potentially hazardous food Include: <br />vegetables, potato salad, eggs, and dairy products. <br />List food to be sold or given to the public:. <br />Asiran , <br />I am providing food that is NOT prepared at home: El Yes No \^o\iS <br />All food is prepared on-site or is from approved ^pmmercial facilitte^R^es O^o^ <^<4- <br />Address of facility:-7- v v <br />I am providing a booth with the following: (to protect my unpackaged food and <br />dust and the public) <br />f^fAbooth 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, dean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />The following is information about my organization/business: <br />Asioq Gccr\e:'< <br />Name of organization/business: 1 \ <br />\.\J . <SX3VSV L-ty-'o Cgx <br />I I Other (specify)^ ,......,3^. ... . - .— <br />Note: The only operations not required to provide endosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />^0^pproved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />Address: <br />T)eAse^-)', <br />a _ P{(*c Ge k\ , v^> I