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Pqu,N Z SAN JOAQUIN COUNTY h <br /> <M D HE <br /> ALTH EALTH DEPARTMENT <br /> M <br /> •. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ��� ��c�Foaa P Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd �'o+�� �. <br /> _NVIROP'P_M;;TAL HFALTI-i <br /> TEMPORARY EVENT APPLICATION PERMIT/SEROCES <br /> To be completed and signed by Event Coordinator, then returned to the Environmental Health Department with all <br /> of the Food Vendor's Applications no later than two weeks prior to event <br /> GENERAL EVENT FILE INFORMATION <br /> 1. Name of Event: �`I U� rv�U C <br /> 2. Date(s)of Event: 0 I Time of Event: <br /> 3. Location: Lvo06t(n>G" f ck-r ' �Ib -•C e I j'V t",1-4 e 6G_ <br /> 4. Event Coordinator(Name): SVI c l 11 (�S S 2� Telephone: (70 �Z <br /> Mailing Address: U G <br /> 5. Number of Food Booths: <br /> � Z <br /> 6. Approximate attendance at peak time: S Total Attendance: 2 60 c Average Age: <br /> UTILITIES <br /> 1. Is potable water supplied and available for each food vendor: EJ<es ❑ No <br /> 2. Is electricity supplied and available for each food vendor: EKes ❑ No <br /> 3. Are janitorial facilities available: 9-�7es ❑ No <br /> 4. Number of toilets provided: �—D / <br /> 5. Name of sanitary garbage disposal company: o v�c (Y16/11CCAi Number of dumpsters: <br /> 6. Method of disposal of liquid waste for food booths: L4 Cec-13 f���/0'► <br /> APPLICATION <br /> 1. Submit the following to the Environmental Health Department two weeks prior to the event: <br /> a) Temporary Event Application <br /> b) Application Review Fee of$130 <br /> c) Temporary Food Vendors Applications for each booth <br /> d) Temporary Event Site Plan <br /> e) Food Vendor List <br /> 2. If the event is selected for inspection, the Event Coordinator will be billed for inspection time: <br /> 0 $130 per hour(weekdays 8:00 am to 5:00 pm) <br /> • After regular business hours (weekday, weekends and holidays)the inspection is charged at the <br /> hourly rate, calculated at one and one half times ($195.00 per hour) <br /> This application is to be completed and signed by the Event Coordinator, then returned to the <br /> Environmental Health Department with all Food Vendor's Applications no later than two weeks prior to the <br /> event. <br /> I understand that as a temporary event coordinator, I am responsible for meeting California State <br /> standards and the Env bnmenta"alth Department policies and procedures. <br /> Event Coordinator: Date: <br /> EHD 16-02 Page 1 of 11 TEMP EVENT APP <br /> 7/14/15 <br />