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SQ N J O G Q U I N Environmental Health Department <br /> 7. Owner's <br /> Statement: <br /> �/ <br /> I,1 1 \/l�lJl t f I Q IYa l.�l� ,agree to grant access to the local health department to <br /> conduct an inspection of my edftage food operation(mark one) <br /> ❑"Class A":In the event of a consumer Uf"Class B": For regular annual facility inspections <br /> complaint or reported food-bome illness and in the event of a consumer complaint or <br /> food-bome illness <br /> 1 � /� 1 �j <br /> I, Y ( t 1)OCA <br /> ICA I eyl JCr\,agree to notify the San Joaquin County Environmental <br /> Health Department prior to moofying 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 /> consignedor given away. <br /> 4C� <br /> Owner's Signature/ Print Name Date <br /> EHO 16-29611171 2 CF 0 REGIPERMITTING RENEWAL FORM <br />