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Environmental Health Department <br />Ogte<s). Sundays Apr-Apri. <br />The following is information about my organization/business:2. <br />Dr) I i-VH-rAddress: <br />PhonR <br />3. <br />4. <br />5. <br />/(rMa"A <br />6.Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />□Approved battled water. <br />9. <br />meats, tamaJes, cooked beans, rice, <br />[ftiiiWi <br />7. <br />8. <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 />O Stemo & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />ZJvesO No <br />Phone: (fl3~S~l <br />Name of organization/business: ttumwioci <br />t“7ro <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 froth tfie ptMc. <br />------COUNTY'—- <br />Greatness grcivs here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />List food to be sold or given to the public: V < kv. <br />1888 E Hazelton Avenue) Stockton, California95205 | T 209 468-3420) F 209 464-0138 | www.sjcehd.com <br />EHD 1SO2 Page 7 of 11 TEMP EVENT APP <br />07/3/17 <br />Note; Examples at potentially hazardous food include: <br />swifrwWhiws, t)otafai<ratefl‘efrds- eml etanria prrwfnr.fs <br />, fe, o <br />I am providing food that is NOT prepared at hornet Yes QTto <br />All food is prepared on-site or is from approved commercial facilities: <br />Name of tadfity: i-t~Cc<v^x Phone: (%5~S~1 <br />Address of faarrtv. ^rQ. -poA C-fhtrr'lm . <br />J am providing a booth with the following: (io protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival cooRfaatar three (3) weeks prtartoWs went <br />1 Name of Event. Weberstown Farmers Market <br />O On-site hose bib that is connected to a potable water source. <br />□ Other (specify/^_______ ___________________________________ ___________ ____________ _ <br />Electricity is provided for my booth’s use: O Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />food&duririg all times of booth operation: Yes Q No <br />I am providing the toftowing hot temperature control for the hot hofcfing of aS potential hsadocs foods above <br />135V: <br />EJ Camp stove <br /> Double steamer <br /> Electric stove top <br />SANJOAOUIN <br />-----------------