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Environmental Health Department <br />iz <br />7/4/251.1. Name of Event:Date(s): <br />2. <br />Address: <br />7/S“Phone: <br />3.7 <br />4. <br />5. <br /> Other (specify): <br />Approved water for drinking, utensil and hand washing will bo provided in my booth by the following methods:6. <br />0 Approved bottled water. <br />9. <br />n.a. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <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 /> Sterno & hotel trays <br /> Steam table & lids <br /> Other (specify) <br />SAN JOAQUIN <br />-------COUNTY------ <br />(neoinrss (/iov/s here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />The following is information about my organization/business: <br />5 /' C ft f ( <br />(<4 utj L? > An <br />sD No J <br />[J] Other (specify): <br />Ek <br />1 1 </ <br />a < <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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 />Independence Day Celebration <br />foods during all times of booth operation: [X] 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 <br />Q Double steamer <br /> Electric stove top <br />. _______________________ _____________7__5V <br />electricity is provided for my booth’s use: 0 Yes NoJ 7 ' <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />I am providing food that is NOT prepared at home: 0 Yes No <br />All food is prepared on-site or is from approved commercial facilities: H Yes No <br />Name of facility: 5 7 Phone: ( ) <br />Address of facility:, <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 />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />EIID 16-02 Page 7 of 11 TEMP EVENT APP <br />07/01/2024 <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 />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br /> On-site hose bib that is connected to a potable water source. <br />5 C I C ty e 6 <br />Name of organization/business: <br />3 6?! Alternate: <br />List food to be sold or given to the public: ‘‘J Uq M T 6 < ,AIT e r 'w / - v <br />Ln