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SAN JOAQUIN <br /> <br />Environmental Health Department <br />N <br />-rittinnurs A COW ioNit-Nr• ,tikinninolc% A rsrs. IF' A T'll'1111 <br />I L.111111-WIArtIrk I F %.0 LJ V I LJ ‘../ 11 '67 ru- r P't I I 1%J 11 <br />A!! fnnil vPnrinrc (brIth fry prrIfif Pnri nnn-prnfit) nt.-P. rPquirPritr) rPtlyn q igr1Pr1 !-Iri nryrp!Pf.Pri nnpy nf thic nhPnk!igt tn <br />the festival coordinator three (3) weeks prior to this event. <br />i . Name of Event: kali y ut -kkt VAjtif Date(s): <br />The following is information about myo anization/business: <br />Address: <br />PhnnP. c20 4I 117 3 <br />List food to be sold or given to the public: -117)-f- ciTc' ailet 1'&h°5 <br />I am providing food that is NOT prepared at homer/6 Yes 0 No <br />All food is prepared on-site or is from approved commercial facilities: Yes 0 No <br />Name of facility: 141 -7r-4/76 Fe41-11(4)Phone: ( 0211 ) 9,7277( <br />L4C/Ite-4 g-1- L b', &PI 509-Yo <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />7 /7 A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, 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 />0 Other (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 />,'proved bottled water. <br />0 On-site hose bib that is connected to a potable water source. <br />E Other (specify): <br />Electricity is provided for my booth's use:.s 0 No <br />I am providing an accurate probe thermom.- to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation;Z Yes D No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />ni Camp stove. ......i......<renn 9 kni,n1 4,-,,,,e- <br />0 Double steamer 0 Steam table & lids <br />0 Electric stove top 0 Other (specify) <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 I Stockton, California 95205 T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />END 16-02 Page 7 of 11 TEMP EVENT APP <br />06/29/2023 <br />Name of organization/business. <br />ea <br />ct (15X c <br />ote.r1 kikcj 9/7)&iltrY? C4 <br />(a1.61 ) CA2 3