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SAN 10 A Q U I N Environmental Health Department <br /> COUNTY--_ <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> City Water ❑ Private Well" <br /> 'If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> 6. Food Processor Course: <br /> Attach food handler certification for owner and each individual that were not submitted with initial application <br /> (including family members and/or employees). <br /> 7. Delivery Limitation: Initial if you agree to abide by the following: -1— <br /> I understand that I may accept orders and payments via the intemet, mail or phone. However, all "Class A" <br /> and "Class B" CFO products must be delivered directly (in person) to the customer. The CFO products may <br /> not be delivered via the United States Postal Service, UPS, FedEx, or using any other indirect delivery method <br /> as deliveries are regulated by, and subject to, CDPH registration and state and federal requirements. <br /> 8. Owner's Statement. <br /> G C) agree to grant access to the local health department to <br /> conduLA an inspection of my cottage food operation (mark one) <br /> ❑ "Class A": In the event of a consumer L."Class B": For regular annual facility inspections <br /> complaint or reported food-bome illness and in the event of a consumer complaint or <br /> food-bome illness <br /> I, Cy{l�t I (Jj/ j a , agree to notify the San Joaquin County Environmental <br /> Health Department prior to modifying my food list, type of operation, and/or method of selling, distributing, or <br /> otherwise providing my CFO products to the consumer or retailers, regardless of whether the product is sold, <br /> consigned, or given away. <br /> nl <br /> ner' ure Print Name Date <br /> 2 oft <br />