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Environmental Health Department <br />(IS <br />I.Name of Event:1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />those which sell beverages from <br />6. <br />the hot and cold holding of potentially hazardous <br />9. <br />meats, tamales, cooked beans, rice, <br />vegetables, potato salad, eggs, and dairy products. <br />7. <br />8. <br /> Approved bottled water. <br />MOn-site hose bib that is connected to a potable water source. <br />SANJOAOUIN <br />------COUNTY------- <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />screening, completely enclosing open food <br />asphalt, clean tarps and smooth wood are < <br />areas from the public. <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />the festival coordinator three (3) weeks prior to this event. <br />-- • Gdtmvils OAZggZ □ate(s):ATkl- <br /> Other (specify):------------- <br />Electricity is provided for my booth’s use: [El Yes No <br />I am providing an accurate probe thermometer; to measure <br />foods during all times of booth operation: 0Yes No ( a t <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: <br />Q^Carnp stove O Sterno & hotel trays <br /> Double steamer O Steam table & lids <br /> Electric stove top Other (specify) <br />Note: Examples of potentially hazardous food include: <br />I am providing food that is NOT prepared at home: 0Tes O No <br />All food is prepared on-site or is from approved commercial facilities. <br />Name of facility: Sk— <br />Address of facility:. <br />I am providing al <br />dust and the public) <br />DTA^booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />1 areas. It will also have a smooth and cleanable floor (concrete, <br />acceptable) and constructed to separate food and food preparation <br /> Other (specify):----------------------------------------------- <br />Note: The only operations not required to provide enclosed booths are <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 />____________ Alternate: ( )____________ <br />UUb'Vx — VfCSCd______ <br />GV\^s <br />'es No <br />ftA Ldck -S OVy,Phone: (36H) ________ <br />... rTvcUrmX ___CA_ <br />booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />The following is information about my organization/business: <br />Name of organization/business: TEEy-U-( <br />da vJLCxkaA____ <br />List food to be sold or given to the public:. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />1 Pthd 7 nf 11 • ClVlr u. V L-IN I Mi lEHD 16-02 Page 7 of 11 <br />07/3/17