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Orchard Valley Mall Farmer’s Market 2O18.jpa4/24/2018 <br />D.E.R. Use Only <br /> PHF Pre-Packaged <br />Phone: <br />Email Address: <br />Zip: *1^0 <br />(QI <br />State: <br />Permit <br />o <br />Date: Operator's Signature: <br />7 <br />1/1 <br /> <br />https://mail.google.com/mail/u/0/?tab=wm#inbox/162dbd6b604cb36e?projector=1&messagePartld-0.1 <br />Islaus <br />State:^ <br />5^3 7 (f <br />(tl 2 ? G <br />Zip: ^^0 <br />County: <br />DEPARTMENT OF ENVIRONMENTAL RESOURCES <br />3800 Cornucopia Way, Suite C, Modesto, CA 95358-9492 <br />Phone: 209.525.6700 • Fax: 209.525.6774 <br />www.stancounty.com <br />4 ~ *5^ <br />Zip: <br /> CFO ^Booth Cart Vehicle Lie <br />Food vehicles must obtain their permit from DER prior to the event. If this vehicle has been permitted in another <br />county within the past 30 days, operator may submit the inspection report in lieu of the inspection. <br />For Veteran's Affair exemption, please attach a copy of form DD-214 to this application for permit. <br />_________ <br />Event Contact Person's Signature: Date: ^-2^- <br />All applications for temporary food permits are to be sutfrfitted to the event organizer for approval. <br />Setup Date: <br />2-8 Q _______ <br />State: qy Zip: <br />Phone: <br />2Qt\ <br />TEMPORARY FOOD FACILITY INFORMATION_________ <br />Business Name: <br />Operator Name: <br />Name of the Booth / Vehicle / Cart: 'y<e.S _____________ <br />Primary Phone: ’7o 7 ‘j Soco Secondary Phone: 'led.'] <br />Address: /J, |Q| <br />City: ______________________ <br />Mailing Address: IGT-OC /J, <br />citje WAlGVj- ' State: Cy\ <br />OFF-site prep: fL/yV 'U <br />Address: | (pT-CO A?. y /6[__________________ <br />City: G/fUCte <br />Will you attend with <br />as a <br />o <br />Stam^^^fis <br />f •• !»• ttti <br />TEMPORARY FOOD FACILITY <br />APPLICATION FOR PERMIT <br />Illegible or incomplete applications may result in delay or denial of permit. <br />(•) Community Event <br />? ^Certified Farmer's Market <br />QSwap Meet (Prepackaged <br />non-PHF only) <br />|V| Yes No <br /> Yes (£1 No <br />Mark one box on the right for the <br />type of event for which you are <br />applying. <br />Have you attended an event in this <br />county within the last 12 months? <br />Event has only one food vendor? <br />COMMUNITY EVENT INFORMATION <br />Name of Event <br />Starting Date: EncPfeate: <br />Address. \/4lty <br />City: ________________________ <br />Organization: M M <br />Event Contact Person: /V\a^s<