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Datefs): April 15,16 & 17, 2016Name of Event: San Joaquin Asparagus Festival1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />7. <br />8. <br />9. <br />Page V2 Rev 10/14/2015 <br />O Electric stove top <br />Other (Specify) <br />-in//a<z <br /> No <br />Name of Organization/Business:. <br />Address: . .. . <br />Phone: <br />List food to be sold or given to the public:,^.cV|n _S ;— <br />(VCZi'i t <br />I am providing foods that are not homemade: £5. Yes No <br />All foods are prepared on-site or are from approved commercial facilities: [^Yes <br />Name of facility: kl jA- ~ —c>>- $ ----------------------- <br />E.H. Permit #:_ <br />I am protecting my unpackaged food and food-preparation areas from flies, dust and the public by the <br />following methods: <br /> A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine <br />mesh fly screening, completely enclosing open food areas. <br /> A booth with a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are <br />acceptable). <br />| | A booth constructed to separate food and food preparation areas from the public. <br />Other (specify): fiullW P -------------------- <br />hlote: the only operations hot required to provide enclosed booths are those which sell beverages from <br />approved 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 />San Joaquin County FOOD VENDOR HEALTH FORM <br />Vendors not in compliance can be asked to close their booth and forfeit the show. <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 organizer two (2) months prior to this event. <br />The following is information about my organization/business: <br />[> UtA (1 * ( V- i <br />/V AyuJi At/ 2-ZkX<z- <br />^2- O .V / - *57 Alternate: <br /> No <br /> Approved bottled water <br /> Hose-bib on-site at the festival. <br />0 Other (specify): - <br />Electricity is provided for my booth’s use: □.Yes <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: S.Yes No <br />providing the following hot temperature control for the hot holding of all potentially hazardous foodsI am <br />’above 140° F: <br /> Camp stove O Double steamer <br />F] Sterno & hotel trays lY^Steam table & lids <br />Note: Potentially hazardous food examples: meats, tamales, cooked beans, rice, vegetables, potato <br />salad, eggs and dairy products. <br />ventlors@SanJoaquinAsparagusFestiv3l.net • 916-370-3647 phone • 209-234-1780 fax