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1. <br />2. <br />Phone: <br />3. <br />4. <br />5. <br />6. <br />9. <br />meats, tamales, cooked beans, rice, <br />7. <br />8. <br />Dilute______ <br />Alternate: ( )---------------- <br />ChiOrrul Is^eSj Cklar.^L <sfe~r <br />1B88E.H«.||<x,A«>nu.| Stockton. Mlbmla852051 T 2094B8-34201 F 209 464-0138 | www.sjoov.oro/eM <br />06'19'19 Page 7 Of 11 TEMp g* <br />.a. Health Department <br />Environmental Hearn > <br />if this checklist to <br />OntCsjSM^l- <br /> Other (specify): <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 /> Approved bottled water. <br /> On-site hose bib that is connected to a potable water source. <br /> Other (specify): /____________ <br />Electricity is provided for my booth’s use: Yes 0 No <br />I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous <br />foods during all times of booth operation: Yes 0No <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 Stemo & hotel trays <br /> Double steamer Steam table & lids <br /> Electric stove top Q'bther (specify) f\\ <br />Note: Examples of potentially hazardous food include* <br />vegetables, potato salad, eggs, and dairy products. <br />SAN JOAQUIN <br />COUNTY----- <br />Gre^ness grow$ here <br />TEMPORARY FOOD VENDOR’S APPLICATION <br />the festivai0/^^-f°r Profi* an<^ nor,-profit) are required to return a signed and completed copy <br />rdmator three (3) weeks prior to this event <br />1 - Name of Event: _ <br />The following is information about my organization/business: <br />Name of organization/business: < I I iC-iV/tf? I u <br />Address: 5^2.45 fynvy <br />List food to be sold or given to the public: <br />I am providing food that is NOT prepared at home: Yes <br />All food is prepared on-site or is from approved commercial facilities: Yes 0 No <br />Name of facility: Phone: 9aS-26)Z <br />Address of facility:.^_ <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 /> A 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 />" ft,55^____________________