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i <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both lor profit and non-profit) are required to return <br />1 I.Name of Event: Date(s)17 <br />2. <br />Address: <br />Phone: <br />3.List food to be sold or given to the public: <br />4. <br />5. <br />L.ZV--OPU <br />6.Approved water for drinking utensil and hand washing will be provided in my booth by the following metnods <br /> Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />9. <br />meats, tamales, cooked beans, rice. <br />.7. <br />8. <br />Note: The only operations not required to provide enclosed booths are those which sell beverages Nor­ <br />approved dispensers or prepackaged foods from approved sources. <br />O Stemo & hotel trays <br />d Steam tabic & lids <br /> Other (specify') <br />)____ _ ______ <br /> <br />SAN JOAQUIN <br /> Alternate: ( <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />a signed and completed copy cf this checklist tothe festival coordinator three (3) weeks prior to this event <br />NA-kO' <br />fc ■ <br />Environmental Health Department <br />Name of organization/business SO, <br /> ... <br /> Other (specify):__________________ _ <br />Electricity is provided forTny booth's use: Yes l^TNc <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during al! times of booth operation: O Yes O No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />ISS’F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />O 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 deanabie 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 />0"Other (specify) <br />i am providing food that is NOT prepared at home: 0 Yes El No <br />All food is prepared on-site or is from approved commercial fadlities: 0'Yes O No <br />Name of facility . - Phone: () 53^, -SO^, <br />Address of facility:S^r. ( € jlkcTo 4 GA ^5307 _______ <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies <br />dust and the public) <br />The foBowtog is information about my organization/business: <br />f 7r7v i-j^r’ * -V-g \ <z- <br />a , c<jas2. _ <br />1868 E. Hazelton Avenue | Stockton, California 95205 I T 209 468-3420) F 209 464-0138 J wvAv.sjcchd com <br />feHO 16-02 Page 7 of 11 <br />O7/3rt7