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<br />DocuSign Envelope ID: A6E74685-DEDE-4900-90F6-8D6DC4F9DF9A <br /> <br />REC-008 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY— <br />Grecitnr.755 grov,'s herc <br />TEMPORARY FOOD VENDOR'S APPLICATION <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 coordinator three (3) weeks prior to this event. <br />4th of July 1.Name of Event: Date(s):: <br />The following is information about my organization/business: <br />\A`NiCA: <br />AddressN,44—+ c--k0Y-c ke(- V-Nrop - <br />Phone: <br />List food to be sold or given lo the public: \ Ui e Q-t t (j.ys_k \-Ve3 <br />I am providing food that is NOT prepared at home: <br />All food is prepared on-site or is from approved commercial facilities <br />Name of facility: Phone: <br />Address of facility: <br />I am providing a booth with the following: (to protect my unpackagecl food and food-preparation areas from flies, <br />dust and the public) <br />booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />s ening, 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 from the public. <br />ilDther (specify): <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 />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />Approved bottled water. <br />n n-site hose bib that is connected to a potable water source. <br />cl)ther (specify): <br />ectricrty is provided for my booth's use lYe No <br />B. I am providing an accurate probe the r -asure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation Ye No <br />9. I am providing the following hot temperatueon1riI tor the hot holding of all potentially hazardous foods above <br />15°F: <br />amp stove <br />ouble steamer <br />lectric stove top <br /> <br />Siemo & hotel trays <br />Steam table & lids <br />Other (specify) <br /> <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenue! Stockton, California 95205 T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Eko i 6-62 Page 74111 TEMP EVENT APP <br />05119119 <br />Name of organization/business: <br />(65 61i 2.2 (;2q(?---, Alternate: (..-.56) 2-9411