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#555 P.001/00203/29/2016 <n'46From:UPS STORE 1064 925 458 0915 Date(s): AG111J5.JL64.1L-2Q161. 2. 3. Phone:, 4. 5. 6. 8. 9. F>«u«>l7rl<. 10714/2015 Electric stove top Other (Specify) San Joaquin County FOOD VENDOR HEALTH FORM Vendors not in compliance can be asked to c?ose their booth and forfest the show. All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to the festival organizer two (2) months prior to this event. Name of Event: San Joaquin Asparagus Festiya.l I am providing foods that are not homemade: Q Yes Alt foods are prepared on-site or are froi Name of facility: / fl(1//Ci E.H. Permit £__________ I am protecting my unpackaged food and food-preparation areas from flies, dust and the public by the following methods: Z0XA booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly screening, completely enclosing open food areas. zZfA booth with a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable), A booth constructed to separate food and food preparation areas from the public. Other (specify):------------------------------------------------------------------------------------———----------- Note: the only operations not required to provide enclosed booths are those which sell beverages from approved dispensers, or prepackaged foods from approved sources. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: ^Approved bottled water EfRose-bib on-site at the festival. Other (specify):. Electricity is provided for my booth’s use. Yes [^fNo I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during ail times of booth operation; J3^Yes No I am providing the following hot temperature control for the hot holding of all potentially hazardous foods 'above 140“ F: Camp stove O Double steamer Sterno & hotel trays 0^team table & lids Note: Potentially hazardous food examples: meats, tamales, cooked beans, rice, vegetables, potato salad, eggs and dairy products. - 316’370'3847 phcae • 203-234-1780 'ax The following is information about my organization/buslness: Name o! ------------------------- Address:. Po WSter_____------------ 3.________AHernate:------------------------------------------------------------- List food to be sold or given to the o ---- Z -S DNO om approved commercial facilities: . Sres U No __________________