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Food Preparation Requirements (includes packaging and handling): <br />Yes No <br />11. <br />Hand washing is required immediately prior to handling foods and after engaging in <br />any activity that contaminates the hands such as after using the toilet, coughing or <br />❑ <br />sneezing, eating or smoking. <br />12. <br />Warm water, hand soap and clean towels are available for hand washing. <br />❑ <br />13. <br />All food ingredients used in the CFO products are from an approved source. <br />E� <br />❑ <br />14. <br />Potable water shall be used for hand washing, ware washing and as an ingredient. <br />Er <br />El <br />15. <br />Is your water source a private well? <br />[0 <br />IJ <br />a. If YES, have you completed testing for bacteria and nitrate? <br />❑ <br />El <br />16. <br />Is your water source a public water system or community services district? <br />_,/ <br />ILI/ <br />❑ <br />a. If YES, what is the name of the system or district? C c sb UN W <br />During the preparation, packaging or handling of CFO products: <br />Yes <br />No <br />17. <br />Domestic activities such as family meal preparation, dishwashing, clothes washing or <br />❑ <br />M <br />ironing, kitchen cleaning or guest entertainment are excluded from the kitchen. <br />18. <br />Infants, small children, or pets are excluded from the kitchen. <br />0' <br />❑ <br />19. <br />Smoking is excluded. <br />U✓ <br />❑ <br />20. <br />Any person with a contagious illness shall refrain from work in the CFO. <br />Er <br />❑ <br />Labeling Requirements: <br />Yes No <br />21. A copy of the label has been submitted to this Department for review and approval. 0' ❑ <br />22. 1 have attached a sample label. t/J ❑ <br />By signing below you are certifying that you meet the requirements of the California Homemade Food Act, AB 1616 <br />(Gatto), as it pertains to a "Class A" Cottage Food Operation. Prior to making any changes, 1 acknowledge that I must <br />notify San Joaquin County Environmental Health Department of any intended changes to the above statement. <br />Cottage Food Operator Checklist completed and submitted by: <br />0" CC :Z lh md5. 0 yczn� el -2'r a a-- <br />Signat re U Print NanY6 Date <br />Ma& to a Mme Ktrhm <br />pemtitE:12345'ImumirtmuNy: SanJooquin <br />'due Tlaw (iwkie <br />�A <br />.S� 95206 <br />4ngreeieJallLLpvpoee.JlwrItlaWNwluvt1Wv, moumGrvMvdj Nucirt, <br />reNum um, Ihiam'u�s munaWrNe, NxiJliwin, f�� <br />47'uxJlwr, Wquufbw. camwr mJlt �9w. °rW° <br />cmw�a cy4e <br />