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y� <br /> SA 6J OAQ U I N Environmental Health Department <br /> : ' —COUNTY— <br /> C, <br /> OUNTYctiFOR` Greatness grows here. RE(DEUVEDD <br /> FEB 24 2020 <br /> REG SOTTAGE FOOD TRAT ON P RMIOPERATIONS FENt <br /> TTING RENEWAL ORM PRMMSERVrENZAL H <br /> CSLH <br /> F Bu 'nes Na v. n <br /> Owner Name: Date: <br /> 01 o <br /> I I C <br /> CFO tyji�.aLAcWress: C O Ci : CFO Zip: <br /> I V1 �5b��]w0 A- 5_ X10 <br /> Website(If appl Telephone: n `J-U9 _ Qn S _ U (a6 V <br /> 1. Categories: <br /> "Class A" (Direct Sales Only) $155 ❑ "Class B" (Direct& Indirect Sales) $310 <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 WIT ALL01lVED. Only <br /> foods that are defined as "non-potentially hazardous" are approved for preparation by a Co e Foo Operation. <br /> These foods include items that do not require refrigeration to keep them safe from bacterial grow at could be a <br /> 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 of <br /> ingredients (attach separate page if needed). <br /> Food List: <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 product is <br /> made). C � n <br /> J <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 /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />