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Environmental Health Department <br />are required to return a signed and completed copy of this checklist to <br />2. <br />3. <br />4. <br />5. <br />6. <br />9. <br />Sieve <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />hree (3) weeks prior tc <br />1. Name of Event: i <br />The following is information about myorganization/business: <br />Name of organization/business:. ‘PaifiT Mgry/p /hr ftsSUMp-hov) fihui_ch <br />Address: -5^3—£__Lpcishi QsYoz, <br />Phone: (qX/I)~ Alternate: ( 7fy)) S7 ~ 70 V <br />List food to be sold or given to the public:IculftS <br />Date(s): ftyj, / 7 <br />-• ^.OUlA/ <br />SANJOAOUIN <br />-----COUNTY------ <br />Greatness groas here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />All food vendors (both for profit and non-profit) ’ <br />the festival coordinator three (3) weeks prior to this event. <br />1. <br />^2HaZeltOnAvenUel Stockton, California 9520^1 209 468-3420 | F 209 464-0138 | www.sjgo^rg/eh^ <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: jS Yes No <br />Name of facility: _________________________Phone; ( } <br />Address of facility:_____________ <br />' te’t and the pX? f°"0Win9: Pr°teCt UnpaCka9ed food and f°°d-preparation areas from flies, <br />s^reln10n0othromnSand T^9 const™ct,fd of either wood’ canvas’ P|as<i=. similar material and fine mesh fly <br />asohal cieXa nt Lnd “"Ih °pe2 areas- 11 wi" also have a smooth and cleanable floor (concrete <br />areas■fromThe public aCCeptable) and constructed separate food and food preparation <br /> Other (specify):________ <br />NOte: annrXri °perations not reqLlirled t0 Provide enclosed booths are those which sell beverages from <br />approved dispensers, or prepackaged foods from approved sources. y <br />Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: <br />B Approved bottled water. <br />B-On-site hose bib that is connected to a potable water source. <br /> Other (specify): <br />Electricity is provided for my booth's use: ® Yes No --------------------------------------- <br />' ^ods^uring a^PtiTesoTboothTpet'ati'om^^Yes □Tq01^6 °f P°tentia"y haZard°US <br />1 a^5pr°vldln9 the follow'n9 hot temperature control for the hot holding of all potentially hazardous foods above <br />0 Camp stove sterno & hotel trays <br /> Double steamer Q steam table & lids <br /> Electric stove top [g Other (specify) |t / (JArr-r <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />•Ch ly <br />nworgamzj <br />n -F I