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SAN JOAQUIN Environmental Health Department <br />TEMPORARY FOOD VENDOR'S APPLICATION <br />I Name o’Event Date<$: lt> <br />Address <br />Pnone Alternate > <br />3 List food to oe sold or given to the pubnC <br />4 <br />y J <br />5 <br />I I Othei tsuecify) __ <br />6 <br />8. <br />9. <br />Coo (MX" <br />meats, tamales, cocked twang, rice. <br />F <br />Note: The only operations not required to provide enclosed booths are those which sen beverages from <br />approved dispensers or prepackaged foods from approved sources <br />. . i-i ft i <br />~ '.:= z I <br />i am <br />ai fc-od is <br />Name of facility <br />Adoress of facility <br />I am <br />i. -i <br />The following is information about my organ•zabon/nusiness <br />Name of organi2abon,fous.ness _ Oil. I/jHL C/y-^ <br /> ---V* \ , yApy / Ck <br />1 6^ <br />V- <br />|l’ " i " 1 tSC,'l‘ ■ .-i : tin <br />£j-i'.i :« :i' <br />I I Sterno & hote: tray <br /> Steam table & ifos <br />Other i soecifv i <br />Noto Examples of potentially hazardous food include: <br />vegetables, potato salad, eggs, and dairy products. <br />A booth witli wails and ceihng constructed of enner wood canvas, plastic sirr.na' matenai ana fine mesh tiy <br />^screening, completely encloaing open food areas it will also nave a smooth and cleanable floor (concrete <br />asphalt, clear tarps and smooth wood are acceptarite; and constructed to separate fcoa and food preparation <br />areas from tne public <br /> Other (specify)_ _____ <br />Efectnciry s proV'decl for imy booth s use^Pf Yes [ ] No <br />i am providing an accurate prooe thermometer to measure rhe hot and cofo holding nt txitentiaily hazanfot-: <br />foods dunnc ail times of booth operation Yes O No <br />i am providing tne following hot temperature control for tne het noklina of all potentially hazardous foods above <br /> Camo stove <br />Double steamer <br />■ Efectn- stove top <br />Approved water for drinking utensil and hand washing will be provided in my oooth uy tne following rrethoas <br />J2j*Approved bottled water <br />[”j On-stte nose bib that is connected to a potable water source <br />providmg food tnat t$ NOT prepared at home J^Tves ~i No <br />prepared on-site rv 15 from approved commercial facilities'jT^Yes C No <br />A vvg i Vclyr\ k Ul 1 Phone ; ^To 1 <br />Jril MJ. »vinvx I i.VE + LA ‘hstir _ <br />providing a booth with the following 'to protect my unpackaged food and food-preparation areas from flies <br />dust and tne public'i <br />. i... ■ 1... ■ih.'i.,■ .1- ' ■ 7 <br />('33= - ■ <br />All rtxjo ver dors ir-oln for pioht and non-profit1 are required id return a signed and completed copy of this checklist to <br />the ’estiva coeroinatoi three < 3 > weeks pr icx to th >5 event