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DocuSign Envelope ID: E100A99A-E0FF-48OF-BFAD-3EFED8C3A0CF <br />Environmental Health DepartmentSAN JOAQUIN <br />All food vendors (both for profit and non-profit) <br />Saturdays 8 30 to 12 30Date(s) <br />1 <br />2 <br />Address <br />) Alternate (Phone <br />ahi tuna, cooked shrimp, chips, rice, soft drinks3 <br />4 <br />5 <br />Q Other (S| <br />6 <br />9 <br />meats, tamales, cooked beans, rice, <br />7. <br />8 <br />1 Name of Event <br />The following is information about my organization/business <br />Chef Hits The Streets <br />iBME Hazekon Avenue| Stockton. California952^1 209468-34201 F 209 464-0138 I-------App <br />EHD 16-02 J <br />screening, completely enclosing open food <br />asphalt, clean tarps and smooth wood are < <br />areas from the public. — <br />ify) ^ood trailer <br />Name of organization/business <br />295 Bonner Dr. Mountain House Ca 95391 <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />-) are required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks pnor to this event <br />River Islands Certified Farmers' Marktd <br />,510363)7616 <br />List food to be sold or given to the public: <br />Note: Examples t <br />vegetables, potato salad, eggs, and dairy products. <br />I am providing food that is NOT prepared at home [?9 Yes No <br />All food is prepared on-site or is from approved commercial facilities. LJ Yes C No <br />Name of facility La Comi sari a Phone gO9-3^8-36§J-------------------------- <br />if I . lit' 1211 S" 7th street Modesto,Ca 95351____ ___________.______________ <br />I am providing a bwthwith the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br /> A „a»s and eei,n9 -s^of e.toer SXZ® <br />acceptable) and constructed to separate food and food preparation <br />Note: The only operations not required to prov.de 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 following methods <br />| | Approved bottled water. <br /> On-site hose bib that is connected to a potable water source <br />□Other (specify): hand wash sink' 3 compartment_sink---------------------------------------------------------------- <br />^am^rovidin^an^cSrSe Verncme^to measure the hot and cold holding of potenbally hazardous <br />f^ds dunng all bmes of booth operation: 0 Yes No <br />I amprovidmg the following hot temperature control for the hot holding of all potentially hazardous foods above <br />ISS’F' Camp stove Stemo & hotel trays <br /> Double steamer Steam table & lids <br /> Electnc stove top Other (specrfy) <br />of potentially hazardous food include: