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Environmental Health Department <br />1. <br />2. <br />Address: <br />Phone: <br />3. <br />4. <br />5. <br />6. <br /> On-site hose bib that is connected to a potable water source. <br />9. <br />meats, tamales, cooked beans, rice, <br />TEMP EVENT APPPage? of 11 <br />7. <br />8. <br /> Other (specify):_______________ ______ <br />Note: The only operations not required to provide enclosed booths <br />1868 E. Hazelton Avenue I Stockton, California 95205 ] T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br />EHD 16.02 Page 7 Of 11 TEMP EVENT A! <br />06119/18 <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <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: FLAkJOX <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 />[XjApproved bottled water. <br />I am providing food that is NOT prepared at home: [Q^Ves No <br />All food is prepared on-site or is from approved commercial facilities: 0*7es Q No <br />Name of facility:Phone: (------)------------------ --------- ----- <br />Address of facility: ---------------------- ------------------------------ ----------- ----------------------- <br />I am providing a booth with the following: (to protect my unpaclcaged food and food-preparation areas from flies, <br />dust and the public) <br />IvTA booth 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 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 />The following is infomnation about my organizafion/business: <br />Name of organlzatlon/business: ^1". 0/- — <br />q is gj . aa A/4 cu Ca <br />) ~7 »^-0 Alternate: ('7c9^') <br />List food to be sold or given to the public: S/IM ---------------------------- <br /> Other (specify):_________ ________ ------------------------—-——— ----------------------------- <br />Electricity is provided for my booth's use: O Yes M No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all limes of booth operation: [vj-Ves EZ] No <br />I am providing the following hot temperature control for the hot holding of all potentially hazardous foods above <br />135°F: . <br /> Camp stove [p'Stemo & hotel trays <br /> Double steamer (Zl Steam table & lids <br /> Electric stove top Other (specify) <br />t sanjoaquin <br />—COUNT Y------ <br />J-iGrc-arne’sr grows here. <br />TEMPORARY FOOD VENDOR’S APPLICATION