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SAN JOAQUIN Environmental Health Department r [�111,€'T y TEMPORARY FOOD VENDOR'S APPLICATION All food vendors(boot for profit and non-profit)are fcquifed to return a signed and completed copy of this chGcHist to the foatival coordinator three(�3))tl weeks ,.tprior to ythisreevenl.. _ 1. 1.Name of Event: L`j_ e j i(e 4FA r �l 1 e- �—Qatf(gj, 2. The following is information about my organization business: Name of organixationlbusiness: 7 N y\na 5 Address: 1, b ,�m s e- C Phone: (aQcj) 4491p,`aZC1Q3 _ Alternate,( J 3. list food to be sold or given to the public:7&k� eE4 CO 4 k(f~S 4. 1 am providing food that is NOT prepared at home:❑Yes 0No All food is prepared on-site or is from approved commercial facilities:❑Yes f-No Name of facility. Phone: Address of facility; S. I am providing a booth with the following:(to protect my unpackaged food and food-preparation areas from flies, dust and the public) ❑A booth with walls and ceiling constructed of either wood,canvas, plastic,similar material and fine mesh fly screening, completely enclosing open food areas. It will also have a smooth and cleanable floor(concrete, asphalt,clean tarps and smooth wood are acceplable)and constructed to separate food and food preparation areas from the pubiie. Cect�S ,1� h2 �2 p�nr � C� bn� Other(specify): Note: The only operations not required to provide enclosed booths are those which sell beverages from approved dispensers,or prepackaged foods from approved sources. 6. Approved water for drinking,utensil and hand washing will be provided in my booth by the following methods: Approved bottled water. ❑On-site hose bib that is connected to a potable water source, ❑Other(specify): 7, Electricity is provided for my booth's use:E]Yes❑No 8_ I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of booth operation:[]Yes❑No 9_ 1 am providing the fallowing hot temperature control for the hot holding of all potentially hazardous foods above 135"F: ❑Camp stove ❑Slemo&&hotel trays ❑Double steamer ❑Steam table&lids ❑Electric stove lop ❑Other(speoffy) Note: Examples of potentially hazardous food Include: meats, tamales, cooked beans, rice, vegetables,potato salad,eggs,and dairy products. 1868 E.Hazelton Avenue I Stockton,California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com E1101602 Pagn7cd 11 TEMPEVIN APP 0)Nt7