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3/4/22, 9:25 AM 20220302_154544.jpg <br />Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />2. <br />Address: <br />Phone:) <br />3.MCX /c/i xl <br />4. <br />5 <br /> Other (specify): <br />6. <br /> On-site hose bib that is connected to a potable water source <br />9. <br />meats, tamales, cooked beans, rice. <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 />7. <br />8. <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />[k^Approved bottled water. <br />SAN JOAQUIN <br />COUNTY <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home: [ZfYes No <br />All food is prepared on-site or is from approved commercial facilities: (ZfYes Q No <br />Name of facility: Phone: (5/0 ) <br />Address of facility: tA/ <br />I am providing a booth with the following: (to protect my unpackaged food ano food-preparation areas from flies, <br />dust and the public) <br />B'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 />1868 E Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 1 F 209 464-0138 | v/ww.sjgovxjrgKehd <br />EHD 16-02 Page 7 0(11 TEKIP EVENT APP <br />06119(19 <br /> Other (specify): <br />Electricity is provided for my booth’s use- Yes B'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: EfYes Q No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />ISST: / <br /> Camp stove 0 Stemo & hotel trays <br />O Double steamer 0 Steam table & lids <br />O Electric stove top O Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Name of orgamzation/business. <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 />I.Name of Event MuLC/JjA/rj AG// /7oTUA^ZiS^(s): 3/1 1^- <br />The following is information about my organization/business: <br /> Alternate: (