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Environmental Health Department <br />i. <br />2, <br />Address: <br />Phone: <br />3. <br />d. <br />5. <br />6. <br />9. <br />i <br /> <br />I ! <br />1. <br />8. <br />... -/■■■■ <br />SANJOAOUIN <br />— COU M TY- - <br />" ''■ '.r '■■•' •• '• <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />I <br />! <br />i <br />?c <br />j <br />f <br />j <br />I <br />I <br />I <br />I I <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist Io <br />the festival coordinator three (3) weeks prior to this event. <br />1 Name of Fvenl'^\L^' — Da(e(s). C/S ! I <br />_____ J 27)2^ <br /> I <br />I <br />rater source. <br />I Viwirtp svsLi'n <br />Yes No d I <br />[eter to measure the hot and cold holding of potentially hazardous <br />^Yes No <br />The following is information about my organization/business <br />Name of organization/business: t<lyS5Cy1' <br />'3Q3L'[_Celeb qd Dryc <br />( ) 64 2. •" Alternate: ( <br />List food Io be sold or given to Hie public: t —ICY! <br />I am providing food that Is NOT prepared at homepg^ Yes □ No <br />All food is prepared on-site or is from approved commercial facilities: J&Yes [71 No <br />Name of facility: fK Phone: --------- <br />Address of facility: jo.Vl C r-fcW ___C-Al-y-Zl^ Z_------------------ <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from fiies, <br />dust and the public) <br /> A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas. Il will also have a smooth and cleanable floor (concrete, <br />asphalt, clean tarps and smooth wood arc acceptable) and constructed to separate food and food preparation <br />areas from the public. \ i ^<7 , i <br /> <br />X°lber(specM W '/ ddcW______ZlkC________________________ <br />Note: 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 will be provided In my booth by the following methods- <br />[J Approved bottled water. <br /> On-site hose bib that Is connected to a potable water <br />^Ollier (specify): . Qi) ——-i— <br />Electricity is provided for my booth's usef^Yes [J No <br />I am providing an accurate probe IhernforRe <br />foods during all times of booth operation; <br />I am providing (he following hot temperatufe control for the hot holding of all potentially hazardous foods above <br />T35“F::- ' / <br />f | Camp stove Slerno & hotel trays <br /> Double steamer □steam table & lids , <br />< Eleclilc stove top pother (specify) H <br />Note; Exampjes of potentially hazardous food include; meats, tamales, cooked beans, rice, <br />.vegetables, potato salad, eggs, and dairy products. <br />1868 E. Hazelton Avenuo | Stockton, California 95205 ( T 209 468-3420 | F 209 464-0138 | VAvw.sjcehd.com <br />' EIIO jC-QZ' '' Pn(ja7of11 l..Mr 1At-NI .’xH <br />07/W \•