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Cll� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' p.' Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.s'cehd.com <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> ,-.(-EQ Business Namer/ d Owner Name: Date: <br /> lo5co el F-4^h/ &ei-ira T9y1 e ID1'�eiH rI fie/��. <br /> CFO Physical Address: CFO City: CFO Zip: <br /> 9�3 6Wler S'KPcyf d-1 ()f- 9s /o <br /> Website(if applicable): Telephone: 73ff—C) <br /> 1. Categories: <br /> ❑ "Class A' (Direct Sales Only) $146 "Class B" (Direct& Indirect Sales) $292 <br /> 2. Prohibited Items: Initial if you agree to abide by the following: <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: <br /> Provide a list of all products you are preparing. If preparing jams,jellies, or fruit butters include a list <br /> of ingredients (attach separate page if needed). <br /> Food List: vt-x Cw, �/ faGitlCs^i Dr�K Slenk-ex Dry 4// X70 <br /> ,P_ak / / <br /> C Gh d Dry ager b c ai! nvlee- <br /> 4. Product Labeling: <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 /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> K City Water ❑ Private Well* <br /> *If a private well, attach all updated water sample results(including quarterly bacteria and Nitrate results.) <br /> EHD 1&297/27/17 1 CFO REG/PERMITTING RENEWAL FORM <br />