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Environmental Health Department <br />10 <br />11. <br />OR <br />12 <br />53 Water supply dispenser witfi warm water at a minimum of 100’ F (i.e 5*20 gaNon container with spigot). <br />Q One separate tub (bucket or basin) for the collectton of rinse/wastewater <br />53 Paper towels and pump*styte soap container <br />13 <br />—Important- <br />Completed by:14. <br />Sig! <br />Health Permit <br />Papat Hand TovoU <br />Garbage <br />Ice Cooler <br />TFMP FVFWr ARP <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />K Three compartment sink <br />cw- <br />5W "»» <br />I am providing the following ooM temperature control for the cold hotdmg of potentially hazardous foods below <br />45*F (if food is used the following day. maintain below 41 *F temperature): <br />£l loe chests Refrigerator <br />O Refrigerated truck Ice bath and tubs <br /> Other (specify)_____ <br />I am providing the followtog for adequate hand washing facilities, but separate from utensil wash within my <br />booth <br />I rfm «■ Oagt < fnaU W» <br />«inofm g 'W& <br />San«Q«r frxAM <br />A Mtei <br />*%Mig <br />SAN JOAQl'iN <br />C OUNT\ <br />Title <br />Q Three deep tubs (basins 6-6 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 />E Detergent, bleach, and wiping cloths (cleaning towels) <br />£3 Tub to store wiping cloths in bleach solution <br />1868 E Hazelton Avenue | Stockton Cawfornia 95205 | T 209 468-34201 F 209 464-0138 | www Sjcehd com <br />EMO '6-02 e ot ! 1 . -. <br />070/17 <br />H 11 W> <br />Date <br />Names of responsible persons to be present in booth during all hours of operation:sey_______________________ ____ <br />All food vendor booths are subject to inspection Ptease make a copy of this appkcation in <br />preparation for this event A copy of this checklist must be in the booth at ail hours of <br />preparation and operation Uffwn Qftainal to ftUhfil CQQfdiMiPf three WWk> prior to <br />this event <br />---------------------- <br />Booth muM be co ) <br />Concrete, Asphalt <br />Plywood or a Tarp [ <br />__________________J