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at+4tn• <br /> r SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax (209) 464-0138 Web:www-s•"ov.or /ehd <br /> f jUli 30 2016 <br /> ENVIRONMENT HE10H <br /> RERMITISERVIEES COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATIONIPERMITTING RENEWAL FORM <br /> i CFO Business Name: <br /> Hlo I-P_ R1 , Date: <br /> CFO Physics!Address: CFO City: <br /> Zi <br /> p: <br /> 42 5 +Jock CFO <br /> Website"(lf applicable): Telephone: <br /> b � z7 0 - 9S <br /> 1. Categories: <br /> "Class A" (Direct Sales Only) $125 ❑ "Class B" (Direct;& Indirect Sales) $250 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: Cv� <br /> Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br /> Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food <br /> Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br /> growth that could be a cause of food-borne illness. <br /> 3. Products: . _ w. <br /> f Provide a list of all products you are preparing. if preparing jams,jellies, or nut butters include a list <br /> of ingredients.(attach separate page if needed). <br /> Food List: <br /> 4. Product Labeiin : <br /> Attach two labels to this form for two of your CFO products (only one label is required if only one <br /> product is made <br /> VIII P .) <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> City Water. ❑ Private Well* <br /> I f 2 private well, attach all updated watersample results (including quarterly bacteria and Nitrate results.) <br /> EHD 16-29 1123/.14 i CFO REG/PERMrFTING RENEWAL FORM <br />