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e'J/14/zk9zz lb:11 zuyjdznzdadaz I Mt UI—'S b I UKt r''Aut U4 <br /> Environmental Health Department <br /> -COUNTY <br /> Crrt7w 11r'1'C. <br /> 10. 1 am providing the following cold temperature control far the cold holding of potentially hazardous foods below <br /> 45'F(if food Is used the following day, maintain below 41°F temperature): <br /> E,A Ice chests ❑ Refrigerator <br /> ❑Refrigerated truck ❑ Ice bath and tubs <br /> 0 Other(specify) <br /> 11, 1 am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br /> ❑Three compartment sink. <br /> OR <br /> gThree deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br /> outlon (one tablespoon of bleach per gallon of water). <br /> ❑Detergent,bleach, and wiping cloths(oleaning towels). <br /> ❑Tub to story wiping cloths In bleach solution. <br /> 12. 1 am providing the following for adequate hand washing facilities, but separate from utensil wash wltM my <br /> booth: <br /> 0 Water supply dispenser with warm water at a minimum of 100°F=(Le,5-20 gallon container with spigot). <br /> 0 One separate tub (bucket or basin)for th©coiiection of rinselwasiewater. <br /> [V'aper towels and pump-style soap container. <br /> 13. Names of responsible persons to he present In booth during all hours of operation: <br /> "Important"* All food vendor booths are subject to Inspeatlon. 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 orl ing1 tc fey vat coordinator threw weeks Prior to <br /> Is event. <br /> 14, completed by: (� V� <br /> gnature Title Date <br /> 8+0 0A <br /> Health Permit H"ndweahWoder <br /> $IQM0 WlChettlRp <br /> al�r <br /> Paper Hand rowete <br /> Seep dladtenear <br /> SanIfterhueket. <br /> bloach A wow tot <br /> Propene Steve Bleach adoring wiping eblhe <br /> 1300111 n1U8t b0 tin <br /> Concmte,Asphalt, <br /> Plywood,or a Tarp. <br /> PropstlgTeSt - <br /> 9:• Sonp nod Water Rlrse walor Blench and Water <br /> Garbaga <br /> Can <br /> E lro!?xflnpulshr� <br /> or <br /> £Kite <br /> i <br /> Ice Cooler 5OalNendwash <br /> l XV0 ko Baps S Food CoMarnem owe[be Wa,etowetor Canlntnar <br /> stored G 7r1oh+,e oNaf rho gm+mrr <br /> 1868 E, Hazelton Avenue I Stockton, Gallfornia 95205 t T 209 468-3420( F 209 464-0138 1 www,sjgov.orglehd <br /> EHD M-02 Psga a or 17 TEMP EVENT APP <br /> 08/1 B119 <br />