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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />1 1 Name of Event Date(s) <br />2 <br />Address <br />Phone <br />3 List food to be sold or given to the public <br />4 <br />5 <br /> Other (specify) <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods6 <br />9 <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 />\/ <br />O'<'/iC <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br /> Approved bottled water <br />^On-site hose bib that is connected to a potable water source <br /> Other (specify) X_____________________________________________ <br />Electricity is provided for my booth's use Fl Yes fl No <br />I 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 />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135 F <br /> Camp stove Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top Other (specify) <br />the festival coordinator three (3) weeks prior to this event <br />1868 E Hazelton Avenue | Stockton. California 95205 | T 209 468-3420) F 209 464 0138 | www sjgov org ehd <br />KHD16 02 Page 7 of tt TEMP EVENT APP <br />06/29/2023 <br />_ Alternate (Jo) ) _ <br />I am providing food that is NOT prepared at home [TfYes No / <br />All food is prepared on-site or is from approved commercial facilities Yes No <br />Name of facility H fC-Phone ( ) 31''’? IS' 7 <br />Address of facility /-'/)<« (PC fQ HQAfloV________________ <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 />0 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 />The following is information about my organization/busmess <br />Name of organization/busmess bo _____________________ <br />( TlH F1) Alternate ) 2/7 7