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Environmental Health Department <br />h i, <br />1. Name of Event:1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />the hot and cold holding of potentially hazardous <br />9. <br />meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8. <br /> Other (specify): <br />Note: The only operations not required to provide enclosed booths <br />Name of organization/business: <br />IA M School Sj- <br />M ___ <br />List food to be sold or given to the public: <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 /> Approved bottled water. ' • <br /> On-site hose bib that is connected to a potable water source. <br />1868 E. Hazelton Avenue | Stockton, California 952051 T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page 7 Of 11 1 bMr cvtN I Ari <br />07/3/17 <br /> Other (specify):____ <br />Electricity is provided for my booth's use: Yes No <br />I am providing an accurate probe thermometer to measure <br />foods during all times of booth operation: O Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove Sterno & hotel trays <br />Q Double steamer Q Steam table & lids <br /> Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food include: <br />\ SANJOAQUIN <br />------COUNTY------- <br />G/Cdl/ICS'. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />i (.u”W <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 to <br />the festival coordinator three (3) weeks prior to this event. <br />Lodi SP____________________Date(s): j ‘t at <br />' mil.The following is information about my organization/business: <br /> <br />idodt I L4 <br /> Alternate: ( ) <br /> pif6drau)hemes pgstrie <br />I am providing food that is NOT prepared at home: Q Yes ^No <br />All food is prepared on-site oris from approved commercial facilities: ®/Yes No <br />Name of facility: -------------------------Phone: (--------)----------— -------------- <br />Addressnffacility: /A /J <S&hV&l Sf /A M <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <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. It will also have a smooth and cleanable floor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public.