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Water Source: Pease Identify the water source to be used in Cottage Food Facility (check one box) Mountain House Community Service X Name of Public Water System or Community Services District: District LI Private Water Supply**, Identify the source (well, spring, surface, etc.): Private Water Supply: Initial Water Quality Results Check boxes below if initial water testing has been completed. All testing must be done at a State Certified Laboratory. Either attach lab results or provide name of lab, date & results in space provided next to type of test. *(Testing frequency for transient Non-Community Water Systems after initial testing) 111 Bacteriological Test (quarterly*): 111 Nitrate Test (yearly*): E] Nitrite Test (every 3 years*): **Additional information may be required if food is prepared from a home with a private water supply — check with local jurisdiction. Food Processor Course: Initial if you agree to abide by the following: XL Within 3 months of being approved to operate by the Environmental Health Department, please provide proof of completion of the California Food Handler course in lieu of the California Department of Public Health (CDPH) food processor course. For more information see CDPH website www.cdph.casiov/procirams/Paqes/fdbCottacieFood.aspx Employee: Initial if you agree to abide by the following: XL I understand that I may not have more than one full-time equivalent cottage food employee, not including a family member or household member of the cottage food operator, working within the registered or permitted area of a private home where the cottage food operator resides and where cottage food products are prepared or packaged for direct, indirect, or direct and indirect sale to consumers. Delivery Limitation: Initial if you agree to abide by the following: XL I understand that I may accept orders and payments via the internet, mail or phone. Direct and Indirect sales may be fulfilled in person, via mail delivery, or using any other third-party delivery service throughout the state of California only. Owner's Statement: Xijiu Li , agree to grant access to the local health department to conduct an inspection of my cottage food operation (mark one) X "Class A": In the event of a consumer 111 "Class B": For regular annual facility inspections and in the event of a consumer EHD 16-27 6/29/2023 6 CFO REG/PERMITTING FORM