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Environmental! Health Department <br />10. <br />11. <br />OR <br />12, <br /> 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 />13. <br />Completed by:14. <br />Signature <br /> Paper Hand Towels <br />Cultinn Hoard <br />Hleadi <br />I <br />fl <br />Ice Cooler I <br />TtMP EVENT APPPage ft of 1 f <br />Reach end Water <br />J <br />Soap arid Water <br />Cxtn> tee Hags Food Con!o.'neis must bo <br />stored 0 Indies o/f o/tho nmind1 <br />5 Gal Hand wash <br />Wastewater Conla’no r <br />Garbage <br />Gan <br />SnnitizerbiicJrol- <br />Weach & water tor <br />sforint) v^ploj ctodis <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br /> Three compartment sink. <br />Steri'ziw/Ctiatfing <br />Dish <br />0-20 Gsf. <br />Hand wash Water <br />SAN lUAIJIJIN <br />c CH J N I Y — <br />I PrcparbiTnnk <br />0 f <br />Title <br />Health Permit <br />Names of responsible persons to be present in booth during all hours of operation: <br /> Sv-y\\W A A O ____________________ <br />**hnportant** <br />I’roparto Stova <br /> Three Cjeep tUbs (basins 6-8 inches minimum), 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 /> Tub to store wiping cloths in bleach solution. <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 priorto <br />this event. / z <br />fY Sicinature Title Date <br />| , I Pre Ex&igufelier <br />ri <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45°F (if food is used the following day, maintain below 41°F temperature): <br /> Ice chests Refrigerator <br /> Refrigerated truck Ice bath and tubs <br /> Other (specify)—------------------------------------------------------ <br />'CT z <br />1868 r- Hazelton Avenue I Stockton, California 95205 | T 209 468-3420] F 209 464-0138 | www.sjcehd.com <br />EIID1O2 PBjjenofll TEMP EVENl <br />0IFMVI