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I- <br /> t <br /> . pr'ri!INC^. 1 <br /> SA N : 1 OA: Q i N Environmental Health De artment <br /> JL 91A <br /> . `k ; �ire � tn � ss grows Dere. <br /> t <br /> 10. 1 am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br /> 45eF (if food is used the following day, aintain below 41 OF temperature) : 1 <br /> ❑ Ice chests Refrigerator <br /> ❑ Refrigerated truck ❑ Ice bath and tubs <br /> EJ Other Other (specify) <br /> i <br /> 11 . I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br /> g fihree compartment sink, <br /> OR <br /> ❑ Three deep tubs (basins 6-8 inches minimum) , one for soapy water, one for rinsing and one for a bleach <br /> solut'on (one tablespoon of bleach per gallon of water) , i <br /> Qtergent, bleach, and wiping cloths (cleaning towels) . <br /> Vb to store wiping cloths in bleach solution . <br /> 12 . I am providing . the following for adequate hand washing facilities, but separate from utensil wash within my <br /> booth : : vl <br /> Water supply dispenser with warm water at a minimum of 100 ° F (Imes 5-20 gallon container with spigot) . <br /> ❑ One separate tub (bucket or basin) for the collection of rinselwastewater, <br /> aper towels and pump-style soap container. <br /> 13. Names o responsible p rsons to be present in booth during all ours of operation : i <br /> "Important" All food vendor booths 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 the booth at all hours of <br /> preparation and ration . Return ori nal to festival coordinator three weeks vrlor to <br /> this event, <br /> 14 . Completed by: v �� „4 Z;�' Gi :v Z// <br /> Signature Title ` Date I <br /> 6-20 Gal. 1 <br /> Health Permit HandwashWater I <br /> sterno w/Chatf ng i <br /> Dish <br /> Paper Hand Towels <br /> Soap dispenser <br /> Curring Board Sanitizerbucket- <br /> bleach & vrater for <br /> Propane Stove Bleach storing wiping cloths <br /> i <br /> Booth must be on <br /> Concrete, Asphalt, <br /> 19 <br /> Plywood, or a Tarp. <br /> Propane Tank ?, a.L fi ¢ i lam' • _ r. 7d;' s <br /> Soap and Water Rinse Water Bleach and Water Garbage <br /> Fire EM(nguisher Can <br /> v � Water <br /> i <br /> I <br /> I <br /> Ice Cooler <br /> � 6 Gal Hand wash i <br /> Extra ice Bags & Food Contalners must he Wastewater Container <br /> stored 6Inehes off of the ground! <br /> , <br /> 1868 E . Hazelton Avenue j Stockton , California 95205 1 T 209 468-3420 j F 209 464-0138 1 www.sjcehd . com <br /> EHD 16-02 Page 6 of 11 <br /> 07/3/17 TEMP EVENT APP <br /> f <br />