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t <br />Environmental Health Department <br />1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />i <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />) <br />£><£> /_______ <br />L-d1> < <br />No <br />__1 <br />SANJOAQUIN <br />------COUNTY------ <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />pleted copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. <br />1. Name of Event: S I'.A -----LL^ <br />The following is information about my organization/business. <br />....... ,: j astt?e~ <br />tXT?; “^?a\rsCXlh Xd are accept) and constraeted .= separate food and food preparation <br />All food vendors (both for profit and non-profit) are required to return a signed and com <br />_______ Alternate: ( <br />t'? z/4 <br /> Other (specify):------------------------------—-—=—------- - ——— <br />h°l a"d “ld holding 0'poten,i*ha2ardous <br />, XoS bo. bet holding of att polendatl, hazardous foods above <br />135OF* <br /> Camp stove Sterno & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top Q Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />Name of organization/business: <br /> <br />(^^r ) 32/ <br />List food to be sold or given to the public: _ <br />I am providing food that is NOT prepared at home:MYes S No <br />Al food is prepared on-site or is from approved commercial facilities: D^TVes <br />, ... Phone: (_Name of facility: ----------------------------------------------------------------------- <br />XToX^ooth Witt, the following: (to profeef my unpackaged food and f.»d.p,ep7ratlon areas from flies, <br />dust and the public) <br />Ma booth with walls and ceiling <br />' -____:___onc'lrrcinn <br />asphalt, clean tarps and smooth wood <br />areas from the public. <br />^Other (specify): Z- <br />Note: The only operations not 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 />^Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />1868 E Hazelton Avenue | Stockton, California 95205 | T 209 468-3420, F 209 464-0138 | <br />EHD1M2 Page 7 of 11 <br />07/3/17 <br /> Date(s): ~ z?