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Environn.^ntal Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />14.Completed by: <br />Health Permit <br />Paper Hand Towels <br />Cutting Board <br />Propane Stove <br />Soap and Water Rinse Water Bleach and Water <br />Ice Cooler <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />Extra Ice Bags & Food Containers must be <br />I stored 6 inches off of the ground! <br />Stemo w/Chaffing <br />Dish <br />Extra <br />Water <br />5 Gal Hand wash <br />Wastewater Container <br />Garbage <br />Can <br />Sanitizer bucket­ <br />bleach & water for <br />storing wiping cloths <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />5-20 Gal <br />Hand wash Water <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />Title <br />Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot) <br />--Ell One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />Ch Paper towels and pump-style soap container. <br />’’Important** <br />Names of responsiblpjDersons to be present in booth during all hours of operation: <br />Date <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />□ Three compartment sink. <br />-0 Three deep tubs (basins 6-8 inches minimum), one for soapy water, one for rinsing and one for a bleach <br />solution (one tablespoon of bleach per gallon of water). <br />H Detergent, bleach, and wiping cloths (cleaning towels). <br />""Q Tub to store wiping cloths in bleach solution. <br />I} am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />SANJOk.iJIN <br />."’W::; —county— <br />Greatness grows here. <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45°F (if food is used the following day, maintain below 41°F temperature): <br />□ Ice chests "^0 Refrigerator <br />□ Refrigerated truck Sj] Ice bath and tubs <br />□ Other (specify)^ <br />Propane Tank <br />F”EKtr'°u"h"r <br />All food vendor booths are subject to inspection. Please make a copy of this application in <br />preparation for this event. A copy of this checklist must be in the booth at all hours of <br />thfe event. / 5 <br />wk CxJ <br />Signature <br />Soap dispenser <br />Bleach