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Environmental Health Department <br />10. <br />11. <br />OR <br />12.my <br />13. <br />14.Completed by: <br />Sb Title <br />Health Permit <br />Paper Hand Towels <br />Soap dispenser <br />Cutting Board <br />Propane Stove Bleach <br />Propane Tank <br />Bleach and Water <br />Fire Extinguisher <br />Ice Cooler <br />1 <br />L <br />Soap and Water Rinse Water <br />J <br />Extra ice Bags & Food Containers must be <br />stored 6 Inches off of the ground! <br />Extra <br />Water <br />Garbage <br />Can <br />Sanitizer bucket­ <br />bleach & water for <br />storing wiping cloths <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />Sterno w/Chaffing <br />Dish <br />5 Gal Hand wash <br />Wastewater Container <br />5-20 Gal. <br />Hand wash Water <br />Zu re <br /> 0 <br />E-Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />H'One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />Paper towels and pump-style soap container. <br />I am providing the following for adequate hand washing facilities, but separate from utensil wash within <br />booth: <br />Names of responsible persons to be present in booth during all hours of operation: <br />vdv ........ <br />..gjiZdioc-Hi IRIpUzo llhru <br />‘‘Important** <br />• Cj c; f U4Hew-1 n Lx,rr-ef z Cmde <br />J__fllpwzo ftAarU P, ___________________ __________________ <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 />preparatioryand operation^ Return original to festival coordinator three weeks prior to <br />this everft. // <br /> c^/u. hi <br />Date <br />P Three compartment^ b°Oth 530113,7 01630109 °f f°Od preParation utensil <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 /> Detergent, bleach, and wiping cloths (cleaning towels). <br /> Tub to store wiping cloths in bleach solution. <br />™n?fin?HaZeltOn Avenuel Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />O6/?9;19 Page 8 of 11 TEMP EVENT ARP <br />SANJOAQUIN <br />------COUNTY------ <br />Greatness grows here <br />' f0^rnf9,f°ld te^Perature control for ‘he “Id holding of potentially hazardous foods below <br />45 l- (if food is used the following day, maintain below 41°F temperature): <br />E Ice chests [g. Refrigerator <br /> Refrigerated truck |Ce bath and tubs <br /> Other (specify)_