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Date(s):2. <br />3. <br />t4. <br />5. <br />those which sell beverages from <br />6. <br />9. <br />tamales,cooked beans,rice, <br />209 464-0138 <br />meats <br />7. <br />8. <br />S4feJM«IN <br />G <br />I WV/W.Slnnv <br />vegetables, potato salad, eggs, and dairy products. <br />Avenue| Stockton,California95205, T 209468-34201 F <br />r r‘ V <br />’I/ ” <br />■- <br />I -Name of <br />The foil, <br />Name of organs <br />Address: <br />Phone: <br />of this checklist to <br />mess: <br />_ Alternate: ( <br />1 fOOd,obesoldor*«toepubiio: Aauo.t FrercAS. <br />* am providing food that is not sz. <br />All food is or PrePare^ at home: Yes No <br />Name of fa Th red|°.n'SlteorisfromaPProvecl commercial facilities: IS Yes No <br />AdZ OoZnAfanrM Phone: -------- <br />Address of facility: 17__\\ <£ -kV d 7_ja .S 3S 1_____ ______________ <br />1 Zrt and Sle areaS flieS’ <br /> A booth with walls and ceiling constructed of either wood, canvas, plastic, similar material and fine mesh fly <br />creening, 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 />Et other (specify): Availer <br />Note: The only operations not required to provide enclosed booths are <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 />Envlronmen.al H-.V O.-"'""* <br /> Other (specify): <br />Electricity is provided for my booth's use: ^Yes No ---------------------- --------------------- <br />' Yes □ NTre ,he h0'and “,d hOld'"9 of potentially hazardous <br />' P£Vidin9 ,he f0"°Win9 hOt ,empera,,Jre con,ro1 for ,he hot holding of all potentially hazardous foods above <br />0 Camp stove D Sterno & hotel trays <br />Q Double steamer D Steam table & lids <br /> Electric stove top ^Other (specify) btfi T <br />Note: Examples of potentially hazardous food include: <br />NTY—_reotne^ grows HHJPUHHimi <br />All food vendon; E,V,PoRARY FOOD VENDOR’S APPLICATION <br />e tosuvat “orana'S^ to^pr^) are reared to retum a signed and eompiered copy <br />1. 1 m„__ . ’ eksPrior to this event <br />-vent: 5 <br />lowinn ■ • IOW|ng IS informatinn u <br />a °ut my organization/business: <br />mtion/business- Oil. / <br />Coca -5—