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w 7 �7�' -��: SAN JOAQUIN COUNTY :. . 7 . ENVIORMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, Califoriiia 95205 4 Business: (209) 468-3420 TLMPOR.ARV FOOD VENDOR'S APPIAC:'ATION All food vendors (both !br profit and non-profit) are required to return a signed and completed copy of-tills checklist to the festival coordinator three (3) weeks prior to this event. 1. Name of Event: Manteca Pumpkji.n Fair _�._ �_. Date(s): October 6-72018 ?. Tile Following is inronnation al)out my organ ization.`business: Ntune of organization /business: Golden State Snacks__.---------_ ..—.----.--__--- -- ---___— Address: 29225 Revis Rd. - Coarse_goid_ CA 93614 Phone:: 559-676--6501 - 3. list food to be sold or given to the public:Pre-packaged nuts, seeds, dried fruit & candy 4. 1 am providing food that is NOT prepared at home- [X] Yes [ ] No All food izi prepared on-site or is from approvcd commercial facilities: p(] Ycs l I No Name of facility: Golden State Snacks Phone: 55_9-Qj6,65Q1____ •Address of facility: 29225R -v s-Rd._�Qarse of _------.--- ----.--__�.-- _.e g d,-.�A-9.2tifi_1-4------ 5. 1 am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, dust and the public) [ ] A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine inesh fly screening, walpletcly enclusiitg Open rood areas. It will also ha%.-c a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood arc acceptable) and constructed to separate Food and Food preparation areas from the public. [ ] Other (specify): Pre-packaged item5-pnly. No food -wj] _be--pr_eparprI nn_site__ ___. _ - Note: The only operations not required to provide enclosed booths are those which sell beverages From approved dispensers, or prepackaged foods from approved sources. 0. Approved water for drinking, utensil and hand washing will be provided in niy booth by the iollowinng methods: [ ] Approved bottled water. [ ] On-site hose bib that is connected to a potable water source. [� Other (specify): 5 gal hand washing station. Using disposable utensils. 7. Electricity is provided for my booth's use: [ ] Yes [X] No 8. 1 am providing an accurate probe thermometer to rneasure the hot and cold holding; of putotitialty hazardous foods during all time of booth operation: [ ] Yes [X] No Not applicable 9. 1 am providing the following hot temperature control for the hot holding of all potentially hazardous foods above 135 degrees Fahrenheit: ] Camp Stove [ ] Double steamer [ ] Electric stove top [ ] Sterno & hotel trays [ ] Steam table & lids Do Other (specify): No hazaLdQU5jogds -_ Note: Examples of potentially hazardous food include: meats, tamales, cooker{ beans, rice vegetables, potato salad, eggs and dairy products. E HD I6-02 rENIP EVEN'r.%pp 07/28/i4