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Environmental Health Department 1. 2. Address: 3. 4. 5. Other (specify): 6. 9. AJ//) meats, tamales, cooked beans, rice, 7. 8. Note: Examples of potentially hazardous food include: vegetables, potato salad, eggs, and dairy products. required to return a signed and completed copy of this checklist to few )C fete . Alternate: ( ) 1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sicehd.com OT/S/I1?'02 Page 7 of 11 TEMP EVENT APP t I am providing food that is NOT prepared at home: j^Yes No All food is prepared on-site or is from approved commercial facilities: Name of facility: /jK Address of facility: 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. It 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. All food vendors (both for profit and non-profit) are r_n_:. the festival coordinator three (3) weeks prior to this event. 1. Name of Event: QCyc C-kV t \ The following is information about my organization/business: Name of organization/business: Phone: 4 j ~ "7/ List food to be sold or given to the public: r V---------- / zc Jh Note: The only operations not required to provide enclosed booths are those which sell beverages from 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: j^Approved bottled water. Q^On-site hose bib that is connected to a potable waler source. Other (specify): Electricity is provided for my booth's use:^<^Yes [~] No I am providing an accurate probe thermometer to measure the hot and cold holding of potentially hazardous foods during all times of booth operation^d’Yes No I am providing the following hot temperalure control for the hot holding of all potentially hazardous foods above Camp stove Sterno & hotel trays o i ! 'y Y) Double steamer Steam table & lids i\\ //\ Electric stove top Other (specify) ilfaSJNJOAQUIN ----COUNTY- Greotness grows here. TEMPORARY FOOD VENDOR’S APPLICATION ^Yes □ No _ Phone: ()