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Environmental Health Department <br />Date(s): 1. <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />cooked beans, rice,meats, tamales, <br />7. <br />8. <br />1868 E. Hazelton Avenue | <br />EHD 16-02 <br />nfi/iQ/tQ <br />I <br />■ <br />I <br />tadXS allhoi holding ol all potentially hazardous foods above <br />I am | <br />135°F: <br /> Camp stove <br /> Double steamer <br /> Electric stove top <br />Note: Examples of <br />t required to provide enclosed booths are those which sell beverages from <br />prepackaged foods from approved sources. <br />id hand washing will be provided in my booth by the following methods: <br />Stockion. California 9520M 1,209 468-34201 F 209 464-0138 I <br />SANJOAQUIN <br />COUNTY <br />Greofness grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION <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 />1 .Name of Event: TOV - <br />The following is information about my organization/business: <br />Name of organization/business: LLC-— <br />Address: QA <br /> ( (C ) Zlll) ________________Alternate: (I~~ --------------- <br />List food to be sold or given to the public: CaFAFII^L—\ P FuS F C-1 2 — <br />I am providing food that is NOT prepared at home: Yes No <br />All food is prepared on-site or is from approved commercial facilities: [^Yes No <br />Name of facility: AolWF TOQD -----------------Phone: <br /> f'X^lngTbooSlnh Ihe^loXuio -T^kagedfood and food-preparatlon areas from Hies. <br />dust and the public) <br />areas from the public. <br /> Other (specify):------------------ <br />Note: The only operations not <br />approved dispensers, or ( <br />Approved water for drinking, utensil am <br />Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br />,he to*and “,d hok)'ns °' poten“y hazWql,S <br />providing the following hot temperature--------- <br /> Stemo & hotel trays <br />q^Steam table & lids <br /> Other (specify) <br />hazardous food include: <br />V^etebies, potato salad, eggs, and dairy products.