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9 <br />Environmental Health Department <br />OR <br />12. <br />Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />[^TPapertowwas and pump-style soap contafoer. <br />13. <br />14.Completed by: <br />Signature <br />Health Permit <br />'Paper HarxTFowvte <br />Propane Stove <br />Wastewater Container <br />Stemo teChsffinp <br />Dian <br />WO Gai. <br />Hand washVMer <br />I am providing the fottowing for adequate hand washing facilities, but separate from utensil wash within my <br />booth- <br />SaniSaarbuckel- <br />bteach & water for <br />storing wlplnc cloths <br />pyxing the following cold temperature control for the cold holding of potentially hazardous foods below <br />(if food is used the following day, maintain below 41 °F temperature): <br />0 Ice chests Refrigerator <br />O Retngeiated truck Q^ebeih and tubs <br />O Other (specify)_______________________________________________________ <br />• trite tuotMV <br />THIe <br />O One separate tob (bucket or basin) for toe ooflecSon of rinse/Wastewater. <br /> Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />soMkxv(one t^espoon of bleach per gafloo of water). <br />Q □■tacgpcC bfeacfu and wiping cloths (daaning towels). <br />LJ tub to. store wiping cloths in bteac^sote^teet <br />Gadtagt. <br />Can <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />Q Three compartment sink. <br />- ■ ■ ■■ ■ \ <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />- ■ - - - <br />1868 E. Hazelton Avenue | Stockton, California 95205 ] T 209 468-3420 J F 209 464-0138 ] www.sjcehd.com <br />EHD1SC2 Page Born TEMP EVENT APR <br />07/3/17 <br />1 OiNWaMri <br />Names of responsible persons to be present in booth during all hours of operation: <br />(\xX\q<s\_____v(YiA<ach Of>d _____________________________ <br />ikKWfS Trcirju'. PrV^SC< O/Mp'0-______________________________ <br />**lnipottanf* Ait food landbc bboths are sutyect to inspection; Please make a copy of this application in <br />preparation for this event A copy of this checklist must be in the boofo at alt hours of <br />orHaaraflongnrf.dderafioft. to testiVafeoortbUtoF teree sreolte atfor to <br />3/27/2021 <br />Date <br />> —COUNTY------ <br />Grsalriess grows here. <br />10- lam <br />Bleach <br />■■■ Rinse Wer Bleach and Waier <br />ExVa <br />MMer