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San JOAQUIN Environmental Health Department <br />TEMPORARY -OOC.I VENDOR’S APPLICATION <br />I Jh j • - j. <br />LI OshH' ■si.'.xify):___ <br />Ap^<u- hjf dunking. and l-a-ul washing will be provided in niy boo’n by the followtng inathodR11 <br />| J O' s I*-: bib that ks connected io .1 uoialjle walnr soikch <br />4i-3 j4. -i . J- ?(>• 1 )r<cj |c I <br />P;<i;o <br />Note. -j •-inly operalions not requi'eii io provide enclosed booths are those, which sell be-ze-rages bom <br />appic/ec dispensers, or prepaekagod rcodf. from approved sources. <br />[_ j Stemo f.\ hotel trays <br />[ J SUism table & lids <br />[J Citicr isuecify) <br />(3ate(s) *fLL <br />| Co' je-'J wa^i/ <br />Nets. ar. 1 ple-’i af potentially nazardoni; include <br />vrgi^abli-s potato ialad eggs arid dairy products. <br />IJ A 1 with walls and ceiling ccr staicled r?f either wood, canvas, plastic, similar material and fine nesh fly <br />screen qi, u:irnplele!y enclosing open kici aieas II will also have a smooth and cleanable floor (concrete, <br />nsph Ji;., clf-n- ia;ps nno smooth wood <re acceptable) ana constructed to separate food and food preparation <br />artw. lue public. <br />Alternate: () <br />Us! o bi: ‘ioid e-giver, to tiv.j public. .'LbfL-C? LCl’luz] t <br />I air- omviding loud that is NOT prepare-'.' at home: I'.j Yes P^No <br />All io r.i is pupa.rjd cn site 01 is tram approved commercial facilities: Yes L; N’> <br />Nam : th'mt.-; h _________________ ___________________ _ Phone. (___)_ _______________ ____ <br />Addr -i of i 1 jlily ............................ ......... ................ <br />I a;r ••."'uviding a booth with the follow r.q (Io protect rny unpackaged food and food-preparation areas from Hies, <br />cut.t iwd I public) <br />1'3 Ch/ (sveoify)._______ ____ _ ____________________ ____________ <br />Efect u.?%. i;; providf'd for my booth’s use fed Yes (. j No <br />I sv? p'UMmp.g an accuralf! probe thrn'-.ynetar to measure the .hot and cold holding of potentially hazardous <br />foe-dr; c'jnng ail times of booth operation: [J Yes fj No <br />I am pioviv'img the I'oilawinq hot 'empmahjre centre! for the hot holding of ai! potentially hazardoun foods above <br />tWP: <br />|'I] Oirnp v:r: •.':•» <br />|_J Ooi.ii'l;? nieamet <br />Lj E eolrm s'O'.e top <br />meats, tamales, cooked beans, rice, <br />-_)NVVJ.^ <br />. .(2P./C- <br />'. .K._ _____ <br />\ll food veno-j'.;. 'huth lor profit and nonprofit) ur? required to return a signed mid completed copy of this checklist to <br />If it; tastival ;uc.!d. i?: lor three (?>) weeks prior to this (want. <br />I f-ta nn t'l drcmi::___ <br />Tne-' > (j-.v 'i is ir formation ebou my crg.ir lizalion/busiriess <br />NaYvii?i rnganizitfior'/businoss:. 5")N vV J.4r _ . 5>/ /|V/^-- __ .. . ... ............. <br />iaM 3.1. . BiZri. .Q^.- > S j..gc.ca: ... <br />........___________________ _ Alternate. () J1&S U 6. 5 S' -.......