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Environmental Health DepartmentSAN JOAQUIN <br />10. <br />11. <br />OR <br />12. <br />13. <br />Date!Completed by14.D.Signature <br />Health Permit <br />ikw) i-oefsct <br />3 <br />IEFT^•-3 <br />W**- <br />s rw F>AwKjirs4^Cf <br />Ice Cooler <br />Exrz <br />e^tAa <br />I am providing the foltowing for <br />booth: <br />$ riM Htnti <br />Caplans <br />S30 <br />-WtJ »S!^ W>*r <br />Soc©' rmKSI be <x> <br />Concrete. Aspr<alt <br />Ptywood. or a Tarp. <br />S««*acr <br />t*Md>&■*»>"»» <br />«nrr«?j »J OC«?»r- <br />£«yj» JtaM i*wa 4 ^>C« Owtiwmrji rtwif <br />iOiijd! ff .nr^sw «>f* v! IfeC <br />one for rinsing and one for a bleach <br />I am providing the following items within my booth for the sanitary cteaning of food preparation utensil <br />|~~| Three compartment sink. <br />□ Three deep tubs (basins 6-8 todies minimum), one for soapy water, <br />scfajlion (one tablespoon of bleach per gaion of water). <br />^Detergent. bteach. and wiping doths (cleaning towels) <br />□ Tub to store wiping cloths in bteach solution. <br />adequate hand washing facilities, but separate from utensd wash within my <br />Gartxaye <br />Can <br />^SC Hazeslob Aventie I SBCktOO. C-fcmi.95JO51 120946S-3420 | F 20948M138 I <br />EHO 16 C2 <br />of.snr <br />I am providing the fdfowing cold temperature control for the cold holding of potentially hazardous foods befow <br />45''F (if food is used the following day. maintain below 41 F temperature) <br />12^ ice chests I j Refrigerator <br />Fl Refrigerated truck p?slce bath and tubs <br />□ other ___________________________________________________________________________* <br />J^Water supply dispenser with warm water at a minimum of 100*F (i e. 5-20 gallon oontetoer with spigot). <br />□ One separate tub (bucket or baste) for the collection of nnsewastewater. <br />?aper towels and pump-style soas container. <br />-|o£jj^'^FA» boX>5 ^e'lbj«r» Please rate, ocwoX^WtiMton'*; <br />preparation for this event. A copy of this checklist must be m the booth at ail tours of <br />preparatfofrand operation. Return original to fcsWai coordinator three w^ks prior .tg <br />/WQL <br />RariZ- j