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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />14.Completed by: <br />Signature Title <br />Health Permit <br />Paper Hand Toweis <br />Soap dispenser <br />Cutting Board <br />Propane Stove Bleach <br />Rinse Water Bleach and Water <br />Fire Extinguisher <br />Page 8 of 11 <br />Stemo w/Chaffing <br />Dish <br />Extra <br />Water <br />5 Gal Hand wash <br />Wastewater Container <br />5-20 Gal. <br />Hand wash Water <br />com <br />TEMP EVENT APP <br />Booth must be on <br />Concrete. Asphalt. <br />Plywood, or a Tarp. <br />Sanitizer bucket­ <br />bleach & water for <br />stoong wiping doths <br />Ice Cooler <br />__________tz <br />“J <br />Q Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />^One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />Paper towels and pump-style soap container. <br />□ Three cXtXOen7s"n9ktemS WitWn my b°Oth Sa™tary c'63™3 °f f00d PreParation Utensil <br />lam providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />uooin. J <br />“Important** <br />SjiJ|rnTnnZetANA^aSi?K|6^HnCheS ™inimum>- one for soaPy water- one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />® Detergent, bleach, and wiping cloths (cleaning towels). <br />SlTub to store wiping cloths in bleach solution. <br />Soap and Water <br />SAN JOAQUIN <br />-----COUNTY------ <br />Greatness grows here <br />1" -ex? ",saax“• <br />E^lce chests Q Refrigerator <br />□ Refrigerated truck Q |ce bath and tubs <br />□ Other (specify), <br />Names of responsible persons to be present in booth during all hours of operation- <br />/ (E.(9ge<|2T__________ __________________’ <br />Garbage <br />Can <br />All food vendor booths 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 all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this event ~ --------- ------------ <br />---- r prA p <br />Title Date <br />Extra Ice Bags & Food Containors must be K <br />stored 6 inches off of the ground’ M <br />EHD ?Jo2 Hazelton Avenue 1 Stockton. California 95205 I 209 468-3420 I F 209 464-0138 | www.sjcehd. <br />07/3/17