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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />14.Completed by: <br />I )lon<-J> mid Wntnr <br />Ice Cooler <br />l<K>.in W.iicr <br />Water supply dispenser with warm water at a minimum of 100°F (i.c. 5-20 gallon container with spigot). <br />One separate tub (bucket or basin) for the collection of rinso/wastewatcr. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />tefrigerator <br />J Ice batt) and tubs <br />!i GhI I land wnnli <br />W.-islowntor Cotibilnor <br />Garliaga <br />Can <br />Snnitlzor buckol- <br />Mondi A w.'itor for <br />alorlng wiping clolhn <br />Booth imisl bo on <br />Concroto, Asphalt. <br />Plywood, ora Tarp. <br />Slmno w/Chnfflng <br />IMsh <br />SANJOAQUIN <br />COUN I Y <br />Ci <-(il ■; Ofnii’. />i>e <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45’F (if food is used the following day, maintain below 41°F temperature): <br />(”] Ice chests 13^' <br />( J Refrigerated truck LI lc< <br />O Other (specify) <br />Date <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />Three compartment sink. <br />[ _] Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />□ Detergent, bleach, and wiping cloths (cleaning towels). <br />O Tub to store wiping cloths in bleach solution. <br />| I’lup.mo Imih <br />J I’ropnno Slow <br />I I »f/a Ice fl.igt A loml Cotilai/ieis must be I [I <br />stoicd 6 hichea oil a/the (iimuidl l;j ( <br />1868 IL Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464 0138 | www.sjcehd.com <br />IW 16-07 I’ntjoflof 11 ■fl-MI’l VI NTAf'P <br />0//.3/I/ <br />^Papcr towels and pump-style soap, container. <br />Names of responsible persons to bo present in booth during all hours of operation: <br />__V-1, ftX.biy I yA cC CtFiih-_____________________________________________ <br />‘‘Important** All food vendor booths are subject to inspection. Please make a copy of this application in <br />preparation for this event. A copy of this checklist must be in the booth at all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />thia event. , <br />■TDcinej-\ivTca|c(y cAavi e/- <br />Signature Title <br />| fio.ip iukI W.rtor <br />I mi Txllrigullliiir | <br />I Health Permit <br />CuUiiig Hoard | . .... <br />I'.ii' u I iiinil I ov.iil-1 | <br />flloach