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Environmental Health Department <br /> <br />i.1. Name of Event <br />2. <br />3. <br />4 <br />5. <br /> Other (specify): <br />Approved water for drinking, utensil and hand washing will ba provided in my booth by the following melfiods:6. <br />9 <br />meats, tamales, cooked beans, rice. <br />TSP SVEN'I APP <br />7. <br />8. <br />Note: The only operations not required So provide enclosed txwchs are those which sell Leverages from <br />approved dispensers, or prepackaged foods from approved sources. <br />Name of organtzabon.bu&ness <br />a,«50 <br />SAN JOAQUIN <br />------COUNrY <br />Grestnrsi urci-rs heir <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />Note: Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />18&BL Hazelton A’/enue | Slacklon. California 95205 | T 209 468-3420 1 F 209 464-0138 | www.sjgov.org/ehd <br />ehd ig-cz pag» z cr n ----ivcrLT A! <br />oanans <br />Date(s). ! ^^-3 <br />The following is infamabon about my organization/business: <br />L-&O 's <br />CA ^5*^ <br />All food vendors (both for profit and non-profit) are required to return a signed and completed copy of this checklist to <br />die festival coordinator three (3) weeks prior to this event. <br />I am providing food that is NOT prepared at home: Ej Yes No <br />Adi food is prepe.redtgmsitgjbr is from approved commercral facilities: EfYes No <br />Name of facility: WUW *5 Phone: < ) <br />Address of facility ___________________________ ________________ <br />I am providing a booth with the f&'lcwing: (to protect my unpackaged food and food-preparation areas from flies, <br />dust and the pubic) <br />EiJA booth with wails and ceding constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />screening, completely enclosing open food areas. It will aso have a smooth and cleanabte floor (concrete, <br />asphalt, clean tarps and smooth wood are acceptable) and constructed to separate food and food prepsraficn <br />areas from the public. <br /> Stemo & hotel trays <br />B'Steam taste & lies <br />0Other (specify) <br />Address: <br />Phone: ( Alternate: {^<0 <br />LSt Sod to W sold « given >o the putfc SBO , WAPOS. <br /> Approved bottled water. <br /> On-site hese bib that is connected to a potable water soiree^ s -n/ gk-i. <br /> <br />Electricity is provided for my tooth's use: [J Yes H No trxvp’ c <br />I am providing an accurate probe thermornet^r to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: (3 Yes No <br />I am providing the following hot temperature control for the hot holding of ail potentially hazardous feeds above <br />135*F: <br /> Camp stove <br />Double steamer <br /> Electric stove top