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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />i: <br />2. <br />Address <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, <br /> ■s <br />7. <br />8. <br />X’i-. <br />SAN JOAQUIN <br />-------COUNTY------- <br />Approved bottled waier. <br /> On-site hose bib that ts connected to a potable water source. <br />screening, completely enclosing open food ; <br />asphalt, clean tarps and smooth wood are ai <br />areas from the public. <br />Other (specify): ^-'0 V 0^0 "WVLV- <br />Note: The only operations not required to provide enclosed booths are <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for drinking, utensil and hand washing will be provided <br />HtvCKtW yiterflfe 95205 I T 209 468-.<420 | F 209 464-0136 , WWAlsfeov <br />FaijO ’ -1 <br />Avonje <br />6hp <br />I am providing food that is NOT prepared at home: Yes No <br />All food is prepared omsite or is from^^rpv^coninKjrcial^cilities: Yes No <br />Address of Facility' ------- ---- <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 matenal and fine mesh fly <br />areas It will also have a smooth and cleanable fleer (concrete, <br />.(.ceptable' and constructed to separate food and food preparation <br /> O’.her 'specify) ___________________ ; <br />-ieutneity ;s provided for my booth's use 0 Yes Q No <br />! am providing ar accurate probe thermometer to measure <br />rc,ods during al! times uf booth operation: C53 Yes O No <br />arr 'ifovidmu in»- »'oUowmq hot temperature control for the hot holding of aH potentially <br />135’F; /• • <br />■"J Camp stove 11 Stemo & hotel trays <br />j Double steamer ® 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 />tamales, cooked beans, rice, <br />All food vendors (both for profit .ind non profit) arc required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. <br />t.Name of Event: .V- ( V- ? (J l) - C.UX-2_._1 _C -D I— <br />The following & information ai?out my organteatiori/busirtsss; <br />Name Qf nrgnfttoatiQn/busrneSs: ..3 ---------- <br /> ffi6zdA<cz4 cP ^^35^________ <br />Phone ! 1 - Alternate: (2 Oq ) (p S2L_ <br />List food tc be sold or aiven to the Dublic<fYXLC>U Pri.gS, <br />kxjccj{t>5z <br />those which sell <br />T>3.. ,»-..>■- <br />in my booth by the foHowing.nwfwW?:^ <br />the hot and cold <br />Date(s) 31^/2^