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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Datc(s). 1.1 Name of Event <br />2 <br />Address <br />Phone <br />3 List food to be sold or given to the public <br />4 <br />5 <br />6 <br />9 <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APP <br />7 <br />8 <br /> Other (specify) ------------------------------------------------------------------------------------------------------------------------- <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 waler 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 I Stockton California 95205 | T 209 468-3420 1 F 209 464 0138 | www sjgov org'ehd <br />EHD 16 02 Pago 7 0(11 TEMP EVENT Al <br />06/19'19 <br /> Other (specify). ———-------—-------------------------------------------------------------- <br />Electricity is provided for my booth's use: Q Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />providing the foltowing hot tempcraturrcontrol for the hot holding of all potentially hazardous foods above <br /> Stemo & hotel trays <br />jS^LSteam table & lids <br />(2j Other (specify) <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 poor to this event <br />Date(s). <br />The following is information about my organization/busmess <br />Name of organization/business [yiC i h $ ..__ <br />15 \]C\ ( | 1 / u J y <br />s') Alternate <br />(_ k I 1 ____- <br />I am providing food that is NOT prepared at home Yes No <br />All food is prepared on-site ocis from approved commercial facilities Yes [~i No <br />Name of facility 1 p 1 P J -r- Phone: ) t .— <br />Address of facility: fl) 14 y J C ^'^11--------------— <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 />fl 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 />Yes No <br />foods during all times of booth operation: 0 Yes No <br />I am j <br />135T: <br /> Camp stove <br /> Double steamer <br /> Electee stove top <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products.