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Environmental Health Departmentiq’ r <br />1.1. Name of Event: <br />2. <br />Address: <br />Phone: <br />3.List food to be sold or given to the public: <br />4. <br />5. <br /> Other (specify): <br />6. <br />Q On-site hose bib that is connected to a potable water source. <br />9. <br />meats, tamales, cooked beans, rice, <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />H'Approved bottled water. <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 />7. <br />8. <br />I am providing food that is NOT prepared at home: Yes Q'fao <br />All food is prepared on-site or is from approved commercial facilities: Yes No <br />Name of facility: J— . . - -. ----------,, , <br />_____________ Alternate: ) <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page 7 of 11 TEMP EVENT APP <br />07/3/17 <br />SAN JOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. <br />The following is information about my organization/business: <br />Name of organization/business: -SV■ L. I M U S' <br />ST.) , <2-4 U <br />(3^5 1 —I & Alternate: 1 <br /> Other (specify): ________________________________________________________ <br />Electricity is provided for my booth’s use: H'Yes No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: H Yes No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br /> Camp stove <br />0 Double steamer <br />0 Electric stove top <br />Name of facility: S i . Ur l-VKL- Phone: (A8<^) <br />Address of facility: Ao a ST", (?> <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />S'A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />0 Sterno & hotel trays <br />0 Steam table & lids <br />Q^Other (specify) fc- <br />Date(s): 3