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Environmental Health Department <br />1. <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />the hot and cold holding of potentially hazardous <br />holding of all potentially hazardous foods above <br />SAN JOAQUIN <br />c O IJ N T V <br />3re le.^red t0 return a s'gned and comP|eted copy of this checklist to <br />Date(s): 3 I I Z~ <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both for profit and non-profit) are kuu;,. ‘ ‘ <br />the festival coordinator three (3) weeks prior to this event. <br />1. Name of Event: <br />The following is information about my organization/business: <br />Name of organization/business: 11 n d CS (Y\€-prVS OceteTl <br />Address: I 4 2- PrSo‘ <br /> Alternate: (7a fl ) ~~ 0344 <br />List food to be sold or given to the public: TC^ <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: r" S ^Vr<v.K phone; ) 34 <br />Address of facility:x, <br />dTsPtand lhe public) (t° my unpacka9ed f°od and food-preparation areas from flies, <br />s°relni^^^ constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />asohaT^iean^ L w areaS’ 11 Wi" als° have a smooth and cleanable floor (concrete <br />areas-fromThepShc aCCeptable) and constructed to separate food and food preparation <br />Q Other (specify): "TT U <br />N°te: Innrn^HHPeratiOnS 001 to pr0Vide enclosed booths are those which sell beverages from <br />pproved dispensers, 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 />B Approved bottled water. <br />El On-site hose bib that is connected to a potable water source. <br /> Other (specify): _________ <br />Electricity is provided for my booth’s use: S Yes No <br />I am providing an accurate probe thermometer to measure <br />foods during all times of booth operation: EJ Yes O No <br />1 Providing the following hot temperature control for the hot <br />__1OO 1. <br /> Camp stove stemo & hotel trays <br />0 Double steamer [^-Steam table & lids <br /> Electric stove top Q other (specify) <br />Note: Examples of potentially hazardous food include- <br />vegetables, potato salad, eggs, and dairy products. <br />EHD?^ Hazel,on Avenue 1 Stockton, California 95205,1 £209 468-34201 F 209464-0138 | www.sjgov.org/ehd