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SAN JOAQUIN COUNTY 4 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />AL4d/CE VE ITNeP hone: (209) 468-3420 Fax: (209) 464-0138 Web: vvww sjcehd com <br />JAN 1 1 2024 <br />COTTAGE FOOD OPERATIONS (CFO) <br />ENVIRONNILIN IAL ri 114 taTRATION/PERMITTING RENEWAL FORM PARINIEN <br />,CFO Business Name: Owner Name: Date: <br />ifL Lt Ni Kic4 U4 jLiDf i - zO 2_ '3 <br />CFO Physical Physical Address: CFO City: CFO Zip: <br />9 pc_t LC, ; by <br />Website (If applicable): Telephone: <br />I A I - 'I 1 <br />,Categories: <br />X "Class A" (Direct Sales Only) $125 El "Class B" (Direct & Indirect Sales) $250 <br />2. Prohibited Items: Initial if you agree to abide by the following: f ' <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br />Only foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food <br />Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br />growth that could be a cause of food-borne illness. <br />Products: <br />Provide a list of all products you are preparing. If preparing jams, jellies, or fruit butters include a list <br />of ingredients (attach separate page if needed). <br />Food List: <br />PlA,/ ( Ok:Le <br />Product Labeling: <br />Attach two labels to this form for two of your CFO products (only one label is required if only one <br />product is made). <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />AC ity Water LI Private Well* <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />END 16-29 6/29/2015 1 CFO REG/PERMITTING RENEWAL FORM