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a <br />Environmental Health Department <br />11. <br />OR for rlnslncj and ona for a bleach <br />12. <br />13. <br />•♦Important**copy of this checklist must be In the booth at all hours of <br />Completed by: 14.Titlenature <br />Health Permit <br />Papar Hand Towois <br />CuWng Board <br />Propane Blove <br />J <br /> XiETi uPropane Tank <br />Bleach and WalerRlnM WaterSoap and Water <br />Fira Extlnouhhor <br />1868 E. Hazelton Avenue | Stockton, California 95205 | 1^209 468-3420 | F 209 464-0138 |TEMP EVENT AFPFHPl 4R-AO <br />I <br />IMSi <br />Slomo vWChafflnfi <br />CNsh <br />Water <br />6 Gal Hand with <br />Wastewater Container <br />S-2O GaL <br />Hand wwah Water <br />Boolh must bo on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />Garbage <br />Can <br />Sanitizer buckM- <br />bleach A water tor <br />storing wtptng cMha <br />lL <br />< ....................................... /■ <br />Ice Cooler ’ <br />iz <br />fQ <br />Extra lite Safia A CorHaitera mtuf ba <br />/tored 0 tochee off of Un gcout\<H <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 waler, one <br />solution (one tablespoon of bleach per gallon of water). <br />Detergent, bleach, ancffilplng 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 wi ' y <br />booth: <br />I So»p dhp»ni>r <br />I <br />II'- <br />\ .. ' <br />I? <br />10. <br />., ,V SANJOAQUIN <br />| ------COUNTY------ <br />A'* ,Grcotncis growi here. <br />'lam providing the following cold temperature control (or the cold holding of potentially hazardous foods below <br />45*F (If food Is used the following day. maintain below 41 F temperature). <br />X'ce chests Refrigerator <br /> Refrigerated truck O lce ba,h and lut>8 <br /> Other (specify)---------------------------------------------—------------------------- <br />ti nsKJ " <br /> Water supply dispenser with warm water at a minimum of 1 GOT (i.e. 5-20 gallon container with spigot). <br /> One separate tub (bucket or basin) for the collection of rlnse/wastewater. <br />r^fpapeTtoweis^nd pump-style soap container, <br />Names ofiesponslble persons to be present In booth during all hours of operation. <br /> Y^A.Vr\CxC^- —-<-------------------------- ----------- -------------------- <br />All food vendor booths are subject to inspection. Please make a copy of this aPPhcat'on In <br />^do" Ind'o^raZ1: Return orig.naf to fes.lvsl coordinator thiee weeks priTcJo <br />this <br /> <br />IDate