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Environmental Health Department <br />1. <br />2. <br />Address: <br />Phone: <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 /> Other (specify): <br />Note: The only operations not required to provide enclosed booths <br /> Approved bottled water. <br />0On-site hose bib that is connected to a potable water source. <br />List food to be sold or given to the public:. <br />CVumJa_______ <br />gsai <br />HW. Date(s): <\d\ <br />■f. <br />Note: The only operations not required to provide enclosed booths are those which sell beverages from <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 />1868 E. Hazelton Avenue] 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 /> Other (specify): s —--------- <br />Electricity is provided for my booth's use: [4 Yes U No <br />I am providing an accurate probe thermometer, to measure <br />I amproviding9 the fXfng'^o^XeX^trol foHhe hot holding of all potentially hazardous foods above <br />135°F: <br />ErCamp stove Sterno & hotel trays <br /> Double steamer O Steam table & lids <br /> Electric stove top Q Other (specify) <br />Note: Examples of potentially hazardous food include: <br />All food vendors (both for profit and non-profit) are required to return a <br />the festival coordinator three (3) weeks prior to this event. <br />1 .Name of Event: < "X <br />The following is information about my organization/business: <br />Name of organization/business: <br />. Co____ <br />Alternate: (cPo^V) _ <br />A 'Jc Ws <br />I am providing food that is NOT prepared at home: 0 Yes Q 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:, CckvcLa -------FrVr) Co.---- <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 />HAbooth with walls and ceiling constructed of either wood, canvas, plastic, similar material ancI fine meshi fly <br />screening, completely enclosing open food areas. It will also have a smooth and cleanable floor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation <br />areas from the public. <br />^.SANJOAQUIN <br />--------COUNTY------- <br />Greotness pro'.vs here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />signed and completed copy of this checklist to <br />FrrMaz natefek \Ll C IT