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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Date(s) AA - OG cud ( { O | <br />2 <br />Address <br />Phone <br />List food to be sold or given to the public 3 <br />4 <br />5 <br />6 <br /> On-site hose bib that is connected to a potable water source <br />9 <br />meats, tamales, cooked beans, rice, <br />7 <br />8 <br /> Other (specify): _____ _____________ — <br />Noto: 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 />'868 E Hazelton Avenue i Stockton. California 95205 ' T 209 468-34 201 F 209 464-0138 j www sjgov org/ehd <br />( H0 u>,02 Page 7 of 11 TEMP EVEN! APP <br />All food vendots (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 />i Name of Event yJkAaA ex 0 X.C \ o < 1 <br />1 he following is information about my orgamzatw/busmess <br />\ \ < ■' ( v c ..s < c kName of orgamzation/business <br /><)H 7)__ <br />(Xt4/ - r H Cl <br />I am providing food that is NOT prepared at home: Q? Yes No <br />All food is prepared on-site or is from approved commercial facilities 3 Yes Ld No <br />Name of facility. f\) ________Phone i---------L------------------------------------ <br />Address of facility frJ ----------------------------------------------------------------------------------------------------------------- <br />I am providing a booth with the following (to protect my unpackaged food and food-preparation areas from fl es <br />dust and the public) <br />Q 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 <br /> Other (specify) ___________________ ____ ____________________________________ <br />Electricity is provided for my booth's use Yes [0 No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation [3 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 Stemo & hotel trays <br />[~] Double steamer Q Steam table & lids <br /> Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />___________________ <br />e f ■, CH <br />Alternate (— IK ^.6— <br />V << $___ _____