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Environmental Health Department <br />Year round <br />11. <br />OR <br />12. <br />One separate tub (bucket or basin) for foe cxatecSon of rinse/wastewater. <br />Papertoweis and pump-style soap container. <br />13. <br />14.Compteted by: <br />Date <br />Stemo ■mJC haffma <br />PaparltandTMnto <br />CuttnsBoart <br />Propane'Stcnro <br />► Propane Tank J <br />IceCxxder <br />Wastowaler Container <br />MO Gal. <br />Hand wash Water <br />Sanitizer buckal- <br />bteach & water for <br />storing wiping ctoths <br />nyfdihg the following cold temperature control for foe cold holding of potentially hazar fiwsdayfe below <br />(if food is i i^HWfolfowkigatfa9,entfolhlartkfetelowl 41 °F temperature): <br />0 Ice chests Refrigerator <br />Q Refrigerated truck and tubs <br />Q Other (specify)KPM (global Online, LLC________ <br />TWe <br />1868 E. Hazelton Avenue | Stockton, California 95205 ] T 209 468-3420) F 209 464-0138 ) www.sjcehd.com <br />EHD 16-02 Page B of 11 TEMP EVENT AFP <br />07/3/17 <br />esne 1^!il^,n§'u^n^ognuertfor 3 bleach <br />Ex&aknStpeAFoafCOAwMsmwklM fl <br />" s <br />Bootfi must be or <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />1 am providing the cleaning of food preparation utensil <br /> Three compartme|y^lg^6 1215 <br /> Three deep tubs (basins 6-8 inches minimum) one for soapy water <br />solution- (one tafetespeon of bleach per gallon of wateq. ” <br />Q OeterganL hfeach, and wiping cloths (ctearwg towels). <br /> Tub to. store wiping ctofos in bleach- sokrifew. fl <br />I am providing the fotio^ing for adequate hand washing faciiities, flit separate^frooigUtensi^wash within my <br />booll i. <br />y 621 Western Ave, Petaluma GA 94252 <br />•H Water supply dispenser with warm water at a minimum of 1 DOT (i.e. 5-20 gallon container with spigot). <br />4^% SAfelWW <br />'? —COUNTY— <br />j-y. ? <br />Greatness grows here. <br />1P- I am <br />4I <br />Names of responsive persons to be present in booth during all hours of operation: <br />(XaX\&<s’._____ycxcuvocX crd ~TOxt\l _______ ____________________ <br />ikioyws EofTYgajr prV^so ____________________________ <br />**lmports«TC* AU food vendor bboths 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 foe booth at all hours of <br />praaarafidft and oceration^ J^etum wliihial to ^foraf «>QRflhMof three weeks prior to <br />3™021 <br />v Signature <br />[ Health Permit <br />GaitMge <br />Can <br />Bleach <br />Bleach and Waler