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Environmental Health Department <br />1.7 ) Date(s): <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />SANJOAQUIN <br />— COUNTY <br />Qu. <br />_ ^^3 CO /yoq <br />( ) 9 H - 0 (p fc I <br />List food to be sold or given to the public: <br />Sr HaZeltOnAVenUe| S“, California 95205J 1 209 468-3420! F 209 464-0138 | www.sj&g/ehdpp <br />-lifrofiv Greofness grows here <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />SeretUm 3 and copy of this checklist to <br />1. Name of Event: llj~ /U^ fy fS fatVl i ly <br />The following is information about my organization/business: <br />Name of organization/business: /Vkryzj /-fac fisSuMphen <br />Address: j9^>3 LOQ’shi n o. 3jt Oft ^52.0^ <br />—_________ Alternate: <br />I am providing food that is NOT prepared at home: 0 Yes No <br />All food is prepared on-site or is from approved commercial facilities: 0 Yes No <br />Name of facility:-------------------------------------------------------------------phone: { <br />Address of facility:. <br />' ^s^andthe pX? Wi‘h f°"0Wir'9: (t0 protect ^packaged food and food-preparation areas from flies, <br />s^reAenbOathcomnSh,aennd X"9 const™ctJd of either w00d' “nvas, plastic, similar material and fine mesh fly <br />asohal TlPAnXt LLd 0Pe. °d are3S '* Wi" also have a smooth and cleanable floor (concrete <br />areas from the pubhc aCCeptable) and constructed to separate food and food preparation <br /> Other (specify):_________________ <br />Note: Innrnvln HPerat'OnS nOt requir,ed t0 Prov'de encl°sed 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 />0- Approved bottled water. <br />0 On-site hose bib that is connected to a potable water source. <br /> Other (specify): <br />Electricity is provided for my booth's use- E Yes No ’ -------------------------------------------- <br />1 toZdXTt“^ the h0t and c°'d h°'di"S * Potentially hazardous <br />1 a^providmg the following hot temperature control for the hot holding of all potentially hazardous foods above <br />0 Camp stove Q Sterno & hotel trays <br /> Double steamer Q steam table & lids <br /> Electric stove top 0 Other (specify) <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products.