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Environmental Health Department <br />^61/1. <br />2. <br /> <br />Address: <br />3. <br />4. <br />5. <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 />Alternate: ) <br /> Approved bottled water. <br />J/fOn-site hose bib that is connected to a potable water source <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />Date(s): \4. C <br />r ........- f->c . . <br />■■■.- -V -• <br />■ : <br />the festival coordinator three (3) weeks prior to this event. <br />I.Name of Event: t> GxA.lLk~.XVlA- <br />The following is information about my organization/business: <br />Name of organization/business: .cAkKAY <br />_____ <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />EHD 16-02 Page 7 of 11 <br />07/3/17 <br />22A <br />Phone: (QCf\ ) ------------------ <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home: ETYes No <br />All food is prepared on-site or is from approved commercial facilities: es No <br />Name of facility: Phone: (^1) ------- <br />Address of facility: CMcU r-mJ,---------f <br />I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the public) <br />[Tf/fbooth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas. It will also have a smooth and c,e^nab’e fl°°r <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />are those which sell beverages from <br /> Other (specify): <br />Note: The only operations not required to provide enclosed booths <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 /> Other (specify):_________ ________ —------------ <br />Electricity is provided for my booth’s use: 0Yes LI No <br />I am providing an accurate probe thermometer, to measure <br />I Jmproviding9 the Xfng°h^ hot holding of all potentially hazardous foods above <br />135°F: <br />HXamp stove Sterno & hotel trays <br />LI Double steamer LI Steam table & lids <br />LJ Electric stove top L) Other (specify) <br />Note: Examples of potentially hazardous food include. <br />ZS S AN JO AQUIN <br /> ...i COUNTY------- <br />Greatness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION