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I7Tii <br />Environmental Health DepartmentSANJOAOUIN <br />1. <br />2. <br />Address. <br />3. <br />4. <br />5. <br />6. <br />9. <br />moats, tamales, cooked beans, rice. <br />7. <br />8. <br />: (r -f 'I 11 f J .I / <br />' U kr '' COUNT Y <br />c *^nr C’reol.'iest ^ro'-vs ^sre. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />AH food vendors (both for profit and non-profrt) are required to return a signed and completed copy of this checklist to <br /> <br />The following is information about rmLoraanijiilion.yisiness: <br />Name of organizationlbusmess: ------------------ <br />I7^Z PlA6LC, CfeFX <br /> Phone: ( 463-1^54___ A,Kma., < .1 sremteii jJiCfe, fW « cui^&STwep, fMisirjfofcKt <br />List food to be sold or given to the Dublic.rsH I flfeCP sKftMEfk, QAR U O OU l HlO , <br />M^AT i u)MfiA, pi 0)to?cA5 cakdO i opa <br />I am providing food that is NOT prepared at home: t/fYes No V^ATEfL - ' <br />AN food is prepared on-site or is from approved commercial facilities: Yes Q No <br />Name of facility: Phone: ( ) <br />Address of facility:___________________________________ <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 />Q 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. <br />Koibe. T hA asifo r-w.ii6K.Wf meets all .s-taiei xmfc. <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 />Approved water for drinking, utensil and hand washing will be provided in my booth by the foifowing methods <br />Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />Hither (specify): ^5 j|JU.J(XW $ Oft <br />Etedrrcity is provided for my booth’s use Yes ^No /------ ---------z~t— x2>. <br />' ^l£rTdt'n9 probe lhernometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: ^YesC No <br />1 an? the following hot temperature control for the hot holding of all potentially hazardous foods above <br />E^Jamp stove Q Stemo & hotel trays <br /> Double steamer (3*Steam table & lids <br /> Electric stove top JJ'Gther (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />;H8b6^. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov org/ehd <br />W/’ * ’9 Pac* ’ ” 'l1 TEMP EVEr< I Ann