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Environmental Health Department <br />10. <br />11. <br />OR <br />12. <br />0 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 />|3 Paper towels and pump-style soap container. <br />13. <br />Ku VI 0s } <br />Completed by:14. <br />Title <br />Health Permit <br />Paper Hand Towels <br />Soap dispenser <br />Cutting Board 3 BleachPropane Stove <br />0nVlD <br />Propane Tank <br />Bleach and WaterRinse Water <br />Fire Extinguisher <br />Ice Cooler <br />TEMP EVENT APP <br />I am providing the following items within my booth for the sanitary cleaning of food preparation utensil <br />0-Three compartment sink. <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 />I am providing the following for adequate hand washing facilities, but separate from utensil wash within my <br />booth: <br />5 Gal Hand wash <br />Wastewater Container <br />5-20 Gai. <br />Hand wash Water <br />Garbage <br />Can <br />Booth must be on <br />Concrete, Asphalt, <br />Plywood, or a Tarp. <br />I am providing the following cold temperature control for the cold holding of potentially hazardous foods below <br />45°F (if food is used the following day, maintain below 41 °F temperature): <br />0 Ice chests O Refrigerator <br /> Refrigerated truck Ice bath and tubs <br /> Other (specify) <br />Extra tee Bags & Eood Containers must be <br />stored 6 inches off of the ground! <br />Stemo w/Chaffing <br />Dish <br />Sanitizer bucket­ <br />bleach & water for <br />storing wiping doths <br />SAN JOAQUIN <br />------COUNTY------ <br />Io5 <br />LO- <br />lake a copy of this application in <br />Date <br />-z- <br />Signature <br />_z <br />Soap and Water <br />1868 E. Hazelton Avenue I Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />1 •“* r. r art r~x m>rTEHD 16-02 ' Page 8 of 11 — --------- <br />07/3/17 <br />Names of responsible persons to be present in booth during all hours of operation: <br />Tji r d \\ *10, sZ'v y s ro 'fShrs b <br />*Hmportant** All food vendor booths are subject to inspection. ^Please fns <br />preparation for this event A copy of this checklist must be in the booth at all hours of <br />preparation and operation. Return original to festival coordinator three weeks prior to <br />this event <br />/tfrUo