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Food Preparation Requirements(includes packaging and handling): Yes No 11. Hand washing is required immediately prior to handling foods and after engaging in any activity that contaminates the hands such as after using the toilet, coughing or ® ❑ sneezing, eating or smoking. 12. Warm water, hand soap and clean towels are available for hand washing. ❑ 13. All food ingredients used in the CFO products are from an approved source. ® ❑ 14. Potable water shall be used for hand washing, ware washing and as an ingredient. ❑ 15. Is your water source a private well? ❑ a.If YES, have you completed testing for bacteria and nitrate? ❑ ❑ 16. Is your water source a public water system or community services district?G N ElES a.If YES, what is the name of the system or district? CAT-f OF AUtb During the preparation, packaging or handling of CFO products: Yes No 17. Domestic activities such as family meal preparation, dishwashing, clothes washing or ❑ ironing, kitchen cleaning or guest entertainment are excluded from the kitchen. 18. Infants, small children, or pets are excluded from the kitchen. ❑ 19. Smoking is excluded. ® ❑ 20. Any person with a contagious illness shall refrain from work in the CFO. ❑ Labeling Requirements: Yes No 21. A copy of the label has been submitted to this Department for review and approval. ® ❑ 22. 1 have attached a sample label. X ❑ By signing below you are certifying that you meet the requirements of the California Homemade Food Act, AB 1616 (Gatto), as it pertains to a "Class A"Cottage Food Operation. Prior to making any changes, I acknowledge that I must notify San Joaquin County Environmental Health Department of any intended changes to the above statement. Cottage Food Operator Checklist completed and submitted by: �,)&P A A N 1 1�A �. "Ar1,l,C - \ -30- 2d Signature Print Name Date EHD 16-26 12/27/2012 2 CFO CLASS A CHECKLIST