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4 <br />Environmental Health Department <br />10. <br />11. <br />OR <br />my12. <br />| | One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />O Paper towels and pump-style soap container. <br />13. <br />Completed by: 14. <br />Health Permit z~ <br />Paper Hand Towels <br />Soap dispenser <br />Cuffing Board <br />BleachPropane Stove <br />][Propane Tank <br />Rinse WaterSoap and Water,Bleach and Water <br />Fire Extinguisher <br />!zlceGooter/ <br />Garbage <br />Can <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />Extra Ice Bags & Food Containers must be <br />stored 6 inches offoTthe ground! <br />5 Gal Hand wash <br />Wastewater Container <br />5-20 Gal. <br />Hand wash Waler <br />Sanitizer bucket­ <br />bleach & water for <br />storing wiping doths <br />Stemo w/Chaffing <br />Dish <br />7/21 / <br />Date <br />‘ SAN JOAQUIN <br />— COUNTY <br />Greatness grows here <br />**lmportant** <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />Q Three compartment sink. <br />fXThree 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 />O Detergent, bleach, and wiping cloths (cleaning towels). <br />EJ Tub to store wiping cloths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within <br />booth: <br />TTWater supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />I amjaroviding the following cold temperature control for the cold holding of potentially hazardous foods beiow <br />45°F (if food is used the following day, maintain below 41 °F temperature;. <br />D Ice chests EZi Refrigerator <br />O Refrigerated truck Sice bath and tubs <br />DI Other (specify)_ ___ _ _ _ <br />1. .' ' <br />Names of responsible persons to be present in booth during all hours of operation: <br />_______C2 TboiG (C/ IKaC-Y'_______________________ ______________________———------------ <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 foe booth at all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this event u' ‘ <br />__________ _________________________________________ <br />Signature______Title_____________Date