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Environmental Health Department <br />Date(s): <br />1. <br />2. <br />Address: <br />3. <br />4. <br />5. <br />which sell beverages from <br />6. <br />9. <br />7. <br />8. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468 3420 | <br />EHD 16-02 <br />07/3/17 <br />209 464-0138 I www.sjcehd.com <br />SAN JOAQUIN <br />----COUNTY — <br /><?ic»vs here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />-) are required to return a signed and completed copy of this checklist to <br />i./j /ml • <br />unpackaged food and food-preparation areas from flies, <br />uGt required to provide enclosed booths are those <br />or prepackaged foods from approved sources. <br />isll and hand washing will be provided in my booth by the following methods: <br />All food vendors (both for profit and non-profit) <br />the festival coordinator thre^ (3) weeks fjnor to this event <br />1. Name of Event: <br />The following Is information about my organUation/busIness: <br />Name of organization/business: — /TJ <br />Va/IA <br />4^^ Phone; (“'C ’ <br />List food to be sold or given to the public; <br />I am providing food that Is NOT prepared at home; t^Yes □ No <br />All food Is prepared on-site or is from approved commercial facilities. ^Yes No <br />______Phone: 1____1 <br />Name of facility:_ ______________ <br />Address of facility:.------------------------------------ — <br />I am providing a booth with the following: (to protect my <br />dust and the public) <br />A booth with walls and ceiling “nstmetecI of either wood.canvas, XnabtetoSuconcrete* <br />a^smS XSab^and constructed to separate food and food preparation <br />areas from the public. <br /> <br /> Other (specify);------------------- <br />Note: The only operations not i <br />approved dispensers, < , <br />Approved water for drinking, utem <br />Q Approved bottled water. <br />j&On-site hose bib that is connected to a potable waler source. <br /> <br />of po,en“al,y "us <br />! aXS "wlng°hot XeXe^or the hot hoidmg of al. potanttally hazardous foods above <br /> Camp stove Sterno & hotel trays <br /> Double steamer -g^team table & <br /> Electric stove top & Other (specify) <br />Note- Examples of potentfaffy hazardous food include: meats, tamaies, cooked beans, r.ce, <br />vegetables, potato salad, eggs, and dairy products.