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Environmental Health Department <br />1. <br />Date(s): <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />food include:meats, tamales, cooked beans, rice, <br />7. <br />8. <br />eHD6^2 Haze"°n Avenue 1 Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd com <br />07/3/17 Page 7 of H TEMP EVENT APP <br />SAN JOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />1.Name of Event: <br />The foltowing is information about my organization/business: <br />Name of organization/business: KhlVlCK <br />Address: ___________ <br />(20Q) 3^’0587 A„t z' , '------------- ------- Alternate: ( ) <br />List food to be sold or given to the public: IfcfOUj yvlg/AJ. ^GQ.OL-<-S <br />I am providing food that is NOT prepared at home: S^Yes No <br />All food is prepared on-site or is from approved commercial facilities: ® Yes No <br />Name of facility: n. J-----------------------------------------------------------------------Phone: ( ) <br />Address of facility:_____ <br />1 admusPt and the **”’ f°"OWin9: (t° P"*** my unPackaSed and foorFpraparation areas from flies, <br />aXs from the PX accePtable) and constructed to separate food and food preparation <br /> Other (specify): <br />N°te; ± °n|V operations not required to provide enclosed booths are those which sell beveraoes from <br />approved dispensers, or prepackaged foods from approved sources. 9 <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />'^Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br /> Other (specify):____________ <br />Electricity is provided for my booth’s use: 0 Yes ® No ——---------------------- <br />' "X%VtiXuXX ,he hot and cold h°ldin9 of poten,ia"y hazard°us <br />' ai35P»r°V'dln9 the f0ll0Wln9 hOt temPera,ure control for the hot holding of all potentially hazardous foods above <br /> Camp stove Q^Sterno & hotel trays <br /> Double steamer Q steam table & lids <br />O Electric stove top • fy^Other (specify) <br />Note. Examples of potentially hazardous f : <br />vegetables, potato salad, eggs, and dairy products.