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i SAN JOAQUIN Environmental Health Department TEMPORARY FOOD VENDOR’S APPLICATION Date(s): I.Name of Event: 1. 2. Address: Phone: 3. 4. 5. those which sell beverages from 6. the hot and cold holding of potentially hazardous 9. meats, tamales, cooked beans, rice, 1868 E. Hazelton Avenue | eno 164)2 06/18/18 All food vendors (both for profit and non-profit) are requ red to return a signed and completed copy of this checklist to the festival coordinator three (3) weeks prior to this event. stockton, California 9520yT( 209 468-3420 I F 209 464-0138 | www-si9^£^pp I am providing food that is NOT prepared at home 0 Yes No All food is prepared on-site or is from approved commercial facilities: Q^Yes Q No Name of facility: Phone. -------------- Address of facility: T-TOtc PfCAlApA __Gft__------------------------------------------------------- I am providing a booth with the following: (to protect my unpackaged food and food-preparation areas from flies, dust and the public) booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly screening completely enclosing open food areas. Il will also have a smooth and cleanable floor (concrete, asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food preparation areas from the public. The following is information about my organizatior/business: Name of organization/business: M~T foftYES v VlX ( Alternate: ( )____ List food to be sold or given to the public: SlQfc HljS OU ClC t / ROOl^vV'. Other (specify): _____________ ______ Note: The only operations not required to provide enclosed booths are approved dispensers, or prepackaged foods from approved sources. Approved water for drinking, utensil and hand washing will be provided in my booth by the following methods: Q^pproved bottled water. On-site hose bib that is connected to a potable water source. 7. ElectricityVprovided for my booth's useJvfYes □ No 8. 1 am providing an accurate probe thermometer to measure 1 am0providing jie'XwIng houXeXe control for the hot holding of all potentially hazardous foods above Camp stove Efsterno & hotel trays Double steamer Q'Steam table & lids □ Electric stove top pother (specify) UW Mote- Examples of potentially hazardous food include: vegetables, potato salad, eggs, and dairy products.