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Environmental Health Department <br />10 <br />11. <br />OR <br />12. <br />13.Names of responsible persons to be present in booth during all hours of operation: <br />“Important** <br />14. <br />Signature ate <br />Health Permit <br />Paper Hand Towels <br />Soap dispenser <br />Cuttnp Board <br />BleachPropane Stove <br />Propane Tank <br />Bleach and Water <br />Fire Extnpuisher <br />Ice Cooler <br />i <br /> Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br /> One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />O Paper towels and pump-style soap container. <br />E/lra Ice Bags & Food Containers must be <br />stored6 inches otto/the giound' <br />Stemo w/Chaffng <br />Dish <br />Extra <br />Waler <br />5 Gal Hand wash <br />Wastewater Container <br />Garbage <br />Can <br />Sanlcrer tx.-ck.et- <br />Pleach & water for <br />storng wpmg cloths <br />Booth must be on <br />Concrete. Asphalt, <br />Plywood, or a Tarp. <br />5-20 Gal <br />Hand wash Water <br />SANJOAOUIN <br />COUNTY <br />Grcotncss grows here. <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45^ (if food is used the following day, maintain below 41 °F temperature): <br /> Ice chests Q Refrigerator <br /> Refrigerated truck Ice bath and tubs <br /> Other (specify) <br />__L <br />Soap and Waler Rinse Water <br />Title <br />lam 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 /> Tub to store wiping cloths in bleach solution. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />OSm/^g02 Pa96 8 °f 11 TEMP EVENT WP <br />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 />this event. » ~1 ~~i <br />Completed by: ------------------- -------------------OCd'nef j22> <br />T)ate <br />I—