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S A N 1 Q A Q U I N Environmental Health Department <br /> COUt,-lTY - <br /> TEMPORARY FOOD VENDOR'S APPLICATION <br /> Ali fcod vendors�Lalh for profit and non-profit)are required to return a signed and completed copy of this checklist to <br /> ,he festival ccordinalorthree(3)weeks prior to this event. oS/o I f <br /> 1. 1.Name of Event: Qate(s): 1�7`� <br /> 2. The following is information about my organizationibusiness- <br /> Name of org;aynizat6onlbusines�ns: SSC'C1 <br /> Address: VAU Wl o-,;fcot1. g <br /> Phone- ac-R 5u22)- O`A Allemate:( ) <br /> 3. List fo=d to be sold or given to the public: ( <br /> Y)d�f QC `a <br /> 4. 1 am providing food that is NOT prepared at home:❑Yes No <br /> Ali food is prepared on-site gr is from approved commercial facilities:❑Yes ktim <br /> �3 o 6q,! <br /> Name of facility <br /> Address of - Gj <br /> CA <br /> 5. 1 am providing a booth with the following:(to protect my unpa aged food and food-preparation areas from flies, <br /> dust and the public) <br /> 0 A booth with wails and ceiling constructed of either wood,canvas,plastic,similar material and fine mesh fly <br /> screen ng, completely enclosing open food areas. It wr71 also have a smooth and cleanable floor(concrete, <br /> asphalt, dean tarps and smooth wood are acceptable)and constructed to separate food and food preparation <br /> areas from the pubCa ,�rt� <br /> !Other(Specify) �v0c\ o�2- <br /> r <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 /> 6. Approved vrater for drinking,utensil and hand washing will be provided in my booth by the following methods: <br /> Approved bottled v:ater. <br /> ❑On-site hose bib that is connected to a potable water source. <br /> ❑Other(specify): <br /> 7. Electricity is provided for my booth's use:❑Yes Mo <br /> 8. 1 am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br /> foods during all times of booth operation:❑Yes❑No <br /> 9. 1 am providing the following hot temperature control for tha hot holding of all potentiality hazardous foods above <br /> 135'F: <br /> ❑Camp stove ❑Sterno&hotel trays <br /> ❑Double steamer ❑Steam table&lids <br /> ❑Electric stove top C Other(specify) <br /> Note: Examples of potentially hazardous food include: meats, tamales, cooked beans, rice, <br /> vegetables,potato salad,eggs,and dairy products. <br /> 18666 E.Hazelton Avenue I Stockton,California 952051 T 209 468-3,120 1 F 209 464-0138 1 wvvw.sjeehd.com <br /> E1re IM2 !'.lad 7 of 11 TEMP EVENT APP <br /> 07r v17 <br />