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Environmental Health Department <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Ail food vendors (both foi profil and non piulrt) <br />Datefs) <br />2 <br />Address <br />5 <br />6 <br />9 <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8 <br />SAN JOAQUIN <br />county <br />3 <br />^rrk /3urri’tD( <br />4 <br />AB food verk^ws (both foi profn and non p«olrt> are required to return a signed end completed copy of the. cbeddtst to <br />the festival coordinator three (3) weeks prior to this event <br />1 Name of Event (2 <br />The following is information about my orpanizalion/business <br />fitK <br />sjpov org'ebd <br />■ rtMP EVENT APP <br />netpr to measure the hot and cold holding of potentially hazardous <br />PjYesONo <br />^ote^hemom^r tonsure the hot and cold holding of potentially hazardous <br />I aXoS cXFoX hot holding of all potentially hazardous foods above <br />135^: <br /> Camp stove Sterno & hotel trays <br />(/^Double steamer [^fsteam table & lids <br /> Electric stove top [/other (specify) <br />Note: Examples of potentially hazardous food include: meats, tamates, cooked beans, rice. <br />C Other (specify): __________ <br />Note: The only operations not required to provide enclosed booths are those which sei! beverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Approved water for dnnking, 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 />Name of oiyanization/business H t c^- A.trwa——i4Z.kXLM-J <br /> <br />Phone. 67^° Alternate: ------------ <br />List food to be sold or given to the public <br />(KcU.1 <br />I am providing food that is NOT prepared at home Yes [^No <br />All food is prepared on-site or is from approved commercial facilities: Yes No <br /> Name of facility; Phone- [-)________ ------------------------- <br />Address o< facility —-----:--------------———— <br />I am providing a booth with the following (to protect rny unpackaged food and food-preparation areas from fnes <br />dust and the public) <br />/'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 />sspnalt, 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 209 408 3420 | F 209 464 0138 , va.w <br />EKJ 16-CQ T t ’ <br />0&2S'2e23 <br />■M