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SANAUALJUIN <br />\ ,Aseer <br />Environmental Health Department <br />"rr ma rt r$ A r”,, r-rt rt Irv- 'ken "r", A nni I" A i-irmia I L.11111- %.00 t II %OWL/ V im.1 la J f‘lr L I %or% II VIII <br />All food vPrifinrs (both for profit ad non-profit) are rAquirPri to return a cignPri and f-nr.nr!PtPri copy of this check!it to <br />the festival coordinator three (3) weeks prior to this event. <br />.i. Name of Event: 7 1 VaJJc - Date(s): <br /> <br />2. The following is information about my organization/business: <br />Name of organization/business: 711e M/A, <br />Address: 5 g t ge 4-6 9/47)-yu cit <br />phone. <br />List food to be sold or given to the public: hit 64',GdT(" -171-171eek , qt.? s' <br />I am providing food that is NOT prepared at home. Yes E No <br />All food is prepared on-sit, or is from approved commercial facilities. Yes 1:1 No <br />Name of facility: /,-00i &Pp( -Fah va phone: (c27) 36,q 7-7-7 f <br />Ackircas of facty: q/3 torbirds7-- is_67(4 51,0 <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 />E 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 />/El Other (specify): --60d rf -Ti&IC- <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 />El Other (specify): <br />Electricity is provided for my booth's use: es 1=I No <br />I am providing an accurate probe thermomet r to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Yes El No <br />I am providing the following hot temperat re control for the hot holding of all potentially hazardous foods above <br />135°F: <br />rs.N rei <br />.6.11 I va V •••• <br />El Double steamer <br />Electric stove top <br />C4,mrmr, b eN+.15i ,IL.,•1 • 1,0 M ., <br />Steam table & lids <br />7E1-Other (specify) T-erd <br />Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />1868 F Ha7elton Avenue I Stockton California 95205 I T 209 468-3420 I F 209 464-0138 I www sionv orniehri <br />EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />06/29/2023 <br />Alternate. ( <br />