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Environmental Health Department <br />10. <br />11. <br />12. <br />Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />13. <br />**lmportant** <br />14.Completed by: <br />Title <br />F <br />Paper Hand Towels <br />Soap dispenser <br />Cutting Board <br />BleachPropane Stove <br />IF <br />Propane T ank <br />Bleach and Water <br />Fire Extinguisher <br />____'______' f <br />Soap and Water <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />□ Three compartment sink. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />Sterno w/Chaffing <br />Dish <br />5 Gal Hand wash <br />Wastewater Container <br />Garbage <br />Can <br />Sanitizer bucket­ <br />bleach & water for <br />stonng wiping cloths <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />^'''"''0 Paper towels and pump-style soap container. <br />Signature <br />Extra <br />Water <br />5-20 Gal <br />Hand wash Water <br />Ice Cooler <br />L___ <br />Rinse Water <br />Extra Ice Bags i Food Containers must be I <br />stored 6 inches off of the ground1 <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page 8 of 11 TEMP EVENT APP <br />07/3/17 <br />| Health Permit <br />SAN JOAQUIN <br />------COUNTY------- <br />Fo-xv’’' 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 ' Refrigerator <br />'''Hj] Refrigerated truck Ice bath and tubs <br />□ Other (specify) <br />Date <br />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 />"^0 Detergent, bleach, and wiping cloths (cleaning towels). <br />^0 Tub to store wiping cloths in bleach solution. <br />Names of responsible persons to be present in boofh during all hours of operation: <br />p Q. i J)_________ <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 />preparation and operation Return original to festival coordinator three weeks prior to <br />-tfiTs^event. / 'A . _ <br />|R