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Environmental Health DepartmentSAN I0AQUIN <br />10 <br />11 <br />OR <br />12 <br />£5 Water supply dispenser with warm water at a minimum of 100uF (i e 5-20 gallon container with spigotj <br /> One separate tub (bucket or basin) for the collection of rinse/wastewater <br /> Paper towels and pump-style soap container <br />13 <br />“Important** <br />Completed by 14 <br />Signature <br />Health Permit <br />Paper Hand Towels <br />Soap dispenser <br />BleachPropane Stove <br />0 <br />Profane Tank <br />Bleach and Water <br />Fire Citmojahcr <br />Ice Cooler <br />EHD 16-02 <br />O7/O1Z2O25 <br />Sterno w Chaffing <br />Dsh <br />Garbage <br />Can <br />Booth must be on <br />Concrete. Asphalt <br />Plywood, or a Tarp <br />Extra Ice Bags & Food Container! must be <br />stored 6 mches off or the ground' <br />Extra <br />Water <br />5 Gal Hand wash <br />Wastewater C<x>!.nrx. <br />5-20 Gal <br />Hand wash Water <br />Sanitcer bucket- <br />bleach & water for <br />storing wiping cloths <br />Names of responsible persons to be present in booth during all hours of operation <br />Title <br />2 <br />Rinse Water <br />Date <br /> Three deep tubs (basins 6-8 inches minimum), one for soapy water <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 />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />(jSsThree compartment sink <br />I am providing the following cold temperature control for the cold holding of potentially i^zai <br />45T (if food is used the following day, maintain below 41 °F temperature) <br /> Ice chests Refrigerator <br />[^Refrigerated truck Q Ice bath and tubs <br /> Other (specify)------------------------------------ - ----------- ------------■" <br />Lz <br />Soap and Walw <br />one for rinsing and one for a bleach <br />1868 E Hazelton Avenue | Stockton. California &5205 | T 209 468-3420! F 209 464-0138 | www sjgov org/ehd <br />-• ■DICC? Page B of 11 TEMP EVENT APP <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, <br />Culling Board