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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />13. <br />14.Completed by: <br />Title <br />Health Permit <br />Paper Hand Towels <br />Soap dispenser <br />Propane Stove Bleach <br />12 <br />Propane Tank <br />Rinse Water <br />Fire Extinguisher <br />Ice Cooler <br />Page 8 of 11 <br />Soap and Water <br />S Water supply dispenser with warm water at a minimum of 100°F (i.e. 5-20 gallon container with spigot). <br />0-One separate tub (bucket or basin) for the collection of rinse/wastewater. <br />® Paper towels and pump-style soap container. <br />Extra Ice Bags & Food Containers must be <br />stored 6 inches off of the ground! <br />Sterno w/Chaffing <br />Dish <br />Garbage <br />Can <br />Sanitizer bucket­ <br />bleach & water for <br />storing wiping cloths <br />S Gal Hand wash <br />Wastewater Container <br />5-20 Gal <br />Hand wash Water <br />r—i i <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, ora Tarp. <br />__________________ y <br />EKD?6 02 HaZeltOn AVenLJe| Stockton- California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />OsXg Page 8 of 11 TEMP EVENT APP <br />?/?£//? <br />Date <br />Three cimptartmllntWs|nnkiterriS With'n b°Oth f°rthe Sanitary cleariir,9 of food preparation utensil <br />but separate from utensil wash within myI am providing the following for adequate hand washing facilities <br />booth: <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 />B Detergent, bleach, and wiping cloths (cleaning towels). <br /> Tub to store wiping cloths in bleach solution. <br />0 -I <br />Cutting Board ____ <br />SAN JOAQUIN <br />-----COUNTY...— <br />Greatness grows here. <br />' the fO^T,3,COld temPerature control for the cold holding of potentially hazardous foods below <br />4b F (it food is used the following day, maintain below 41°F temperature): <br />B Ice chests 0. Refrigerator <br /> Refrigerated truck ice bath and tubs <br /> Other (specify)__ <br />J <br />N&rries of responsible persons to be present in booth during all hours of operation: <br />fCi'l I at__Ifurlarh,. Ir^c Qarram <br />att Ort^cp_________ _____________________________ ' <br />“Important** 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 />preparation anc^operation. Return original to festival coordinator three weeks prior to <br />this event. X / 7 <br />Signature