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'` EI SAN JOAQUIN COUNTY %a <br /> ENVIRONMENTAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT ,SUN 2 1 2017 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax.(209)464-0138 Web:www.siceh ONMENTAL HEALTH <br /> pERI!I MSERVICES <br /> COTTAGE FOOD OPERATIONS (CFO) <br /> REGISTRATION/PERMITTING RENEWAL FORM <br /> CFO Business Na e: Owner Name: Date: <br /> CFO Physical Address: CFO City: CFO Zip: <br /> iia c R <br /> Website(It applicable): Telephone:lnwa6c SL - <br /> `cilm 7J <br /> 1. Categories: <br /> ❑ "Class X (Direct Sales Only)$125 -Class B" (Direct & Indirect Sales)$250 <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: tzlm <br /> -!- CkLLOw <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 /> R <br /> a 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 /> EHD 16-29 6/29/2015 1 CFO REG/PERMITTING RENEWAL FORM <br />