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Environmental Health Department <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />mected to <br />Iding of potentially hazardous <br />9. <br />meats, tamales, cooked beans, rice,Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8. <br /> Other (specifeLx \ <br />tlectricity is provided for my booth’s use: [V <br />I am providing an accurate probe therm^mf <br />foods during all times of booth operation: t <br />I am providing the following hot temperature <br />135°F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br /> Sterno & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />SAIWOAQUIN <br />------COUNTY------- <br />Greatness, grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />The following is information about my organization/business: <br />2Z>, p <br />I am providing food that is NOT prepared at home: Yes No <br />All food is prepa. <br />Name of facility <br />Address of facility: ?' <br />I am providing a boofr <br />dust and the public) <br />,4®^ <br />©to <br />j <br />stable water source, p <br />res No <br />eter to measure the hot and cold <br />^Yes No <br />Control for the hot holding of all potentially hazardous foods above <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 I www.siqov.orq/ehd <br />oe/w/w02 Page 7 of 11 TEMP EVENT APP <br />on-site^is fromrapproved CQQT/ierciarfacilitiesj[ <br />)JrK /) / /IjW <br />’ith the rolwing: (I <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />^^Approved bottled water. <br /> On-site hose bib thatjs^ <br /> 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 cleanable floor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public \ n <br />Other (specify): ) 0YJ ■« <br />/Note: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />the festival coordinator three (3) weeks prior to this event. <br />I.Name of Event: <br />Name of organization/business: <br />vo } ca ________ <br />(20^ ) Alternate: ~ <br />List food to be sold or given to the public: U/XXxXA IZVU <br />Ing: (to protect my unpackaged food and food^dparatioirateas from flies, <br />Date(s):