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Environmental Health Department <br />11. <br />OR <br />12. <br />13. <br />14.Completed by: <br />Signature Date <br />Health Permit <br />Psp«H»MJTowrt» <br />BleachPropane Stove <br />I Propene Tank <br />Rinse Water Bleach and Water,, Soap and Water <br />IceCooler <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br /> Three compartment sink. <br />SJemo w/Chaffino <br />5 Gal HandvMBh <br />Wastewater Container <br />MO Gai. <br />Hand svasti Water <br />I am <br />4S <br />Sanitizer buckat- <br />bteach 8. water for <br />storing wtp ng .-.loths <br />Gaitege. <br />Can <br />TW« <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth^ <br />^^fwater supply dispenser with warm water at a minimum of 100oF (i.e. 5-20 gallon container with spigot). <br />-Cfone separate fob (bucket or basin) for the coiiecSon of rinse/wastewatw. <br />0^per towais and pump-style soap container. <br /> Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />sohjtkxY (one tafcfespoon of bleach per gaWon of water) <br />□. Qetafgant, tfeach, and wiping ctoihs (cleaning towels). <br />LJ Tub to. store wiping cloths in bteach- soWtort <br />SANJOAWIN <br />tWW'- ’■? — COUNT Y------ <br />Greainess grows here. <br />10- l am pravidir’9 the following cold temperature control for the cold holding of potentially hazardous foods below <br />453F(if food is used the following day, maintain below 41 °F temperature): <br />0lce chests Refrigerator <br />GRefogereted truck G^ebalh and tubs <br />O Other (specify) <br />j Soap &per>Mf <br />Fire Exbofpjrsher I <br />------------------------------------X <br /> Booth must be on <br />Concrete, Asphalt, <br />■T Plywood, or a Tarp. <br /> F V _______ <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page B of 11 TEMP EVEMT AFP <br />07/3/17 <br />Names of responsible persons to be present in booth during all hours of operation: <br />Ouj(\fc<s_____XY\CkA<ocX ord _______________________________ <br />1>AOY\Q<S £(X~VVCaCU' _________________________________ <br />**fmpoftant** Ait food ienrfx bboths are subject to inspection. Please make a copy of this application in <br />preparation for this event A copy of this checklist must be in the booth at alt hours of <br />prepwation and. aperation^^eeum ftree ptfor to <br />ttiisgvent-^ // March 2o22 <br />f Board