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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />**lm portant** <br />14. <br />Signature <br />Health Permit <br />Paper Hand Towels <br />Soap dispenser <br />Cutting Beard <br />Bleach <br />Propane Stove <br />[Propane Tank <br />Fire Extinguisher <br />Ice Cooler <br />TEMP EVENT APP <br />Extra <br />Water <br />5 Gal Hand wash <br />Wastewaler Conlalnor <br />5-20 Gal- <br />Hand wash Waler <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />Sanitizer bucket­ <br />bleach & water for <br />storing wiping doliis <br />Sterno w/Chaffing <br />Dish <br />Garbage <br />Can <br />Title <br />__z <br />Soap and Water Rinse Water <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 I www.sjcehd.com <br />EHD 16-02 <br />07/3/17 <br />Exira Ico Bags & Food Containers must bo <br />stored S inches off of the ground! <br />Bleach and Water | <br />SAN JOAQUIN <br />: ------COUNTY------- <br />Greotnen grows here. <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45°F (if food is used the following day, maintain below 41 °F temperature): <br />□ Ice chests ^Refrigerator <br />□ Refrigerated truck O *ce bath and tubs <br />jSfother (specify) ----------------------------------------------------------------- ---------------- <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />Three compartment sink. <br />□ 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 />□ Detergent, bleach, and wiping cloths (cleaning towels). <br />Q 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 my <br />booth: <br />££Water supply dispenser with warm water at a minimum of 100°F (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 />Names of responsible persons to be present in booth during all hours of operation: <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 three weeks prlorto <br />' - ....... <br />DateCompleted by: _j