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Environmental Health Department <br />required to return a signed and completed copy of this checklist to <br />1.1. Name of Event: Date(S): January 11, 2025 <br />2.The following is information about my organization/business: <br />Name of organization/business: <br />10403 EL PASO WAY/ STOCKTON CA-95209Address: <br />Phone:Alternate: () <br />3.List food to be sold or given to the public: _____________________ <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice. <br />7. <br />8. <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Note: The only operations not required to provide enclosed booths <br />approved dispensers, or prepackaged foods from approved <br />are those which sell beverages from <br />sources. <br /> 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 />areas fro01^ SmOOth WOOd are accePtable) and constructed to separate food and food preparation <br />KOther (specify): FACILITY KITCHEN AREA <br />SAN-JOAOUIN <br />------COUNTY------ <br />Greotness grows here <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both for profit and non-profit) are i <br />the festival coordinator three (3) weeks prior to this event. <br />Q On-site hose bib that is connected to a potable water source. <br />other (specify): FACILITY KITCHEN AREA AND CONCESSION BOOTHS <br />Electricity is provided for my booth’s use: EJ Yes No ' " <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: KI Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove Stemo & hotel trays <br /> Double steamer gf Steam table & lids <br /> Electric stove top other (specify) <br />I am providing food that is NOT prepared at home: Yes No <br />All food is prepared on-site or is from approved commercial facilities: KI Yes No <br />Name of facility: STOCKTON civic AUDITORIUM Phone: ( ) <br />Address Of facility: 525 N. CENTER STREE/STOCKTON CA 95202 <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 />( 209 ) 992-9R <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br /> Approved bottled water. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 I wwwsjcehdcom <br />^117W)2 Page7of11 TEMP EVENTAPP