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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1. <br />2 <br />Address <br />Pt xxw <br />3 <br />4 <br />5 <br />6 <br />9 <br />Ao A <br />meats, tamales, cooked beans, rice. <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8 <br />SAN JOAQUIN <br />COUNTY <br />AH food wrxlocs (both for prof t and non profit) .vc required to return n s.qnr'd and completed copy of this ct.<*ck’.st to <br />the festival coordmator throe (3) \veeks prtrz io this event <br />i Name of Event^OxO- dff |oS O Date(s)- Il | *^-1 ^4~ <br />1668 E. Hazeion Avenue | SlocMOd. CaWomla 95205 | T 209 468-34201 F 209 464-0138 | www sjgo^^ehd <br />£HD1fC2 EMr> I a xt Al. <br />074)14024 <br />The fottowng Is information about my orqanizat orvVjsmess <br />Name of organtoitKYi/business; W.d.vA I _______________ <br />ZzrVnYpp 0^- ^533° <br />( 5101 ^3^4 ___ After nate ( ) <br />List food to be sold or given to the pub c. Ct>otu-*S j 3UXpA V~XCA.yM AXjvc. <br />I am pravidng food that rs NQT prepared at home Yes No ------------------ --- <br />Ah food is prepared on site or fa from approved commercial facilities. Yes (2fNo <br />Name of far iMy Rhone ( I <br />Address of facuity;__________________________ <br />I am prowid-ng a booth with the following (to protect my unpackaged food and food-preparation areas from hies, <br />dust and the pubic) <br /> A booth with wafc and ceiling constructed of cither wood, canvas, plastic similar materkil and fine mesh hy <br />screening, complclciy enclosing open food areas It will also have a smooth and ciearable floor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food .and food preparation <br />areas from the pubic <br />Cg1 Other (specify): J uqA\ <br />Note: The only operations not requred to provide enclosed booths ane those which sell beverages from <br />approved dispensers or prepackaged foods from approved sources <br />Approved water for drinking, utensil and hand wasfung wtll be provided In my booth by the following methods. <br />'ffAppr oved bottied water <br /> On-site hose b.0 that is connected to a potable water source. <br />□ Oiher (specify): Z VqjUA, \VdCcuyd --------------------------------------------------------- <br />Electricity is provided for my booth s use- H Yes No <br />I am providing an accurate fxobe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during ail times of booth operation Yes 3No <br />I am providing the following hot temperature control for the hot holding of ail potentially hazardous foods above <br />135T.- „ <br /> Camp stove Stemo & hotel trays <br />O Double steamer D Steam table & lids <br /> Electric stove top 'Q'Olher (specify)^ <br />Note: Examples of potentially hazardous food include: