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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. 63 ❑ 14. Potable water shall be used for hand washing,ware washing and as an ingredient. ® ❑ 15. Is your water source a private well? ❑ 53 a.If YES, have you completed testing for bacteria and nitrate? ❑ ❑ 16. Is your water source a public water system or community services district? � " J9 ❑ a.If YES,what is the name of the system or district? jj __ l 1/,fitV l rf�h•" r4 la Yes No During the preparation,packaging or handling of CFO products: 17. Domestic activities such as family meal preparation, dishwashing,clothes washing or 19 ❑ ironing, kitchen cleaning or guest entertainment are excluded from the kitchen. 16. 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. ® ❑ ey signing below you are certifying that you meet the requirements of the California Homemade Food Ad, AB 1616 (Gatto),as it;pertains to a*Class A"Cottage Food Operation. Prior to making any changes, I admowiedge that I must notify San Joaquin County Environmental Heap Department of any intended changes to the above statement. Cottage Food Operator Checi t completed and submitted by. Signature Pant Name Date EHo 1626 i2r2rr[6/2 2 CFO CIASSA CHECKUSr