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C'herie's (Pies <br />SAUOAQUIN <br />COUNTY <br />Delivery Limitation: <br />Environmental Health Department <br />Initial if you agree to abide by the following: CZ) <br /> <br />I understand that I may accept orders and payments via the Internet, mail or phone. However, all "Class A" and <br />"Class B" CFO products must be delivered directly (in person) to the customer. The CFO products may not be <br />delivered via the United States Postal Service, UPS, FedEx, or using any other indirect delivery method as <br />deliveries are regulated by, and subject to, CDPH registration and state and federal requirements. <br />Owner's Statement: <br />1, (LI/etre 5E6LE1E , agree to grant access to the local health department to <br />conduct an inspection of my cottage food operation (mark one) <br />LII "Class A": In the event of a consumer "Class B": For regular annual facility inspections <br />complaint or reported food-borne illness and in the event of a consumer complaint or <br />food-borne illness <br />I, H 6 SE 6 L EiC , 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 /> <br />CREgI6 5E6tee- <br />Print Name <br /> <br />3-2.0Z0 <br />Date <br /> <br />Owner's Signature <br /> <br />IC" <br />Cherie Segler .° .t2 <br /> <br />17971 N Tretheway Rd 3 () <br /> <br />Lockeford, Ca 95237 t) ol -0 t <br />Mill.1111111111111111.11.11.1111111111".. <br />ccii .1, a) <br />.F.; a' <br />E t <br />Ingredients: Unbleached flour(wheat flour, niacin,reduced iron,u wn <br />thiamine, mononitrate, riboflavin, and folic acid), Fruit, Sugar, ..7.7.. i.... r <br />Vegetable shortening, Cornstarch. Salt, Cinnamon, Nutmeg <br />it 2 .... --8 <br />Contains: Wheat <br />4.' 0 <br />' <br />Made In A Home Kitchen 1-- -= <br />,T, -., IL- <br />0 0 z - d g .g <br />Permit #PT0025226 . 'V 1, :o n <br />Issued In San Joaquin County ai t•-• c ci. <br />— € 6 <br />ra? 16 <br /> <br />Net Wt 2.5,bs (40.0 oz -Y CU s:, :•,4 <br />122 <br />1 i <br />23c E <br />g..g >, E r, <br />2.-. a <br />2 of 2