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Environmental Health Department <br />_Date(s) ,1. <br />2. <br />Phone: <br />3 <br />4. <br />5 <br />6. <br />.pproved bottled water. <br /> On-site hose bib that is connected to a potaWe water source. <br />9 <br />meats, tamales, cooked beans, rice. <br />EVENT AF^P7 nt n <br /> Sterno & hotel trays <br />Q Steam tabte & lids <br /> Other (specify) <br />7. <br />8. <br />SAN JOAQUIN <br />------COUNTY------- <br />Gic-vPieiJ y/Ok*s <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />AM food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />tt>e (estival coordinator three (3) weeks prior to this event <br />1. Name of Event: ( Datefs) ^01^ <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenue | Stockton. California 95205 | T 209 458-3420 | F 209 454-0138 | www.Sjgov org/ehd <br />DO 16-32 F’W* 7 nf 11 TEM-” EVENT AJ <br />□ Other (spedfy) T&0. <br />Noto: The only operations not required to provide enclosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing vdl be provided in my booth by the following methods: <br /> Other (specify): ___________________________ <br />Electricity is provided for my booth's uso [ztres ; 3 No <br />I am providing an accurate probe thermorneterzlo measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Qtes H No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135’F: <br />Fl Camp stove <br />C] Double steamer <br /> Electric stove top <br />List food to be sold or given to the public: _____. - <br />Gj \J /t/4c 4* a <br />I am providing food that is NOT prepared at home: Yes | ] No <br />All food is prepared on-site or is from approved commercial facilities. [_l YfeS F I NO <br />Name of facility: (< 1 - Ph9°e: ---------- <br />Address of Z- 7 e ------------------------------------------- <br />I am providing a booth with the follwr-ng (to protect my unpackagod food and food-preparaton areas from flies. <br />dust and the public) <br /> A booth with walls and ceiling constructed of either wood., canvas, plastic, similar material and fine mesh 1y <br />screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br />asphalt dean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />Address / <br />USiOa. Musfc <br />Tne following is information about my organizatlon/business: Name of organization/business <br />7eS f-tj Ct Ae z-i _________