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Environmental Health Department <br />1.I.Name of Event <br />Z <br />Address: <br />5. <br />6. <br />9. <br />186^E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 [ www.sjgov.ora/ehd <br />7. <br />8. <br />SANJOAOUIN <br />-----COUNTY------ <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Bfooubte steamer <br /> Electric stove top <br />Note; Examples of potentiany hazardous food include: <br />vegetables, potato sated, eggs, and datay products. <br />>' >r <br />__► <br />Datefs): <br />3. List food to be sold or given to the public: /T? StrflA "IaC*}, (jl <br />4. I am providing food that is NOT prepared at home: 0 Yes sNo <br />AD food is prepared on-sie or is from approved commercial facilities: £3 Yes No <br />Name of facfity:Phone: ( ) <br />Address of facility: <br />I am providing a booth wih the following: (to protect my unpackaged food and food-preparation areas from fifes, <br />dust and the pubfic) <br />0 A booth with wafts and ceAng constructed of either wood, canvas, plastic, sanfiar material and fine mesh fly <br />screening, completely enclosing open food areas. It wffl also have a smooth and cteanatole floor (concrete, <br />asphalt, dean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br /> Other (specify):’_____________________ ___________ ___________________ <br />Note: The only operations not required to provide enclosed booths are those which sei beverages from <br />approved dfepensers, 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 />O On-site hose bfo that is connected to a potable water source. <br /> Other (specify):__________________x Efectricity is provided for my booth’s use: O Yes rU^o • ? <br />1 aJn proyd*19 an accurate Probe thermometer lo measure the hot and cold holding of potenfiaBy hazardous <br />foods dunng al times of booth operation: 0 Yes O No <br />1 1116 foiowin9 temperature control for the hot holding of al potently hazardous foods above <br />Elpamp stove Q Stemo & hotel trays <br />Efsteam table & lids <br />Q^ther (specify) fcvriW <br />meats, tamales, cooked beans, rice. <br />AH food vendors (both for profit and non-profit) are required to return a signed and completed copy of this ctteckfist to <br />the festival coordinator three (3) weeks prior to this event <br />The fbOowing is information about my organization/business: <br />Name of organization/business: /ti kya Jdz/fJ LtX .< <br />3-.^o iWc. K-AayiVeriT- <br />Phone: Alternate, (^j) <br />List food to be sold or given to the public: fit HQ O- (ft ^TA^JJy