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Food Preparation Requirements (ip It!dw. '110 11anrlling): Yes No 11. Hand washing is requhed ww ,i i, I-, ,r to handling fords and after engaging in ❑ any activity that contaniinales I!^,. iA, as after using the toilet, coughing or sneezing, eating or smoking. 12. Wami water, hand soap and to wee arF available for hand washing. ❑ 13 All food ingredients used in the CFO products are from an approved source. � ❑ 14. Potable eater shall be used for hand washing, ware washing and as an ingredient ❑ 15. Is your water source a private well? ❑ a.If YES, have you completed testing for bacteria and nitrate? ❑,/ ❑ 16. is your water source a public water system or community services district? 4� ❑ a.If YES, what is the name of the system or district? 5 A M _3©A CM N C 0 LI N I y During the preparation, packaging or handling of CFO products: Yes No 17. Domestic activities such as family meal preparation, dishwashing, clothes washing or ❑/ ❑ ironing, kitchen cleaning or guest entertainment are excluded from the kitchen. 18. Infants, small children, or pets are excluded from the kitchen. ® -- ❑ 19. Smoking is excluded. 0 ❑ 20. Any person with a contagious illness shall refrain from work in the CFO. e ❑ 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. �❑ I By signing below you are certifying that you meet the requirements of the California Homemade Food Act, AB 1616 (Gatto), as it pertains to a "Class A"Cottage Food Operation. Prior to making any changes, I acknowledge that I must notify San Joaquin County Environmental Health Department of any intended changes to the above statement. Cottage Food Operator Checklist completed and submitted by: SriRt`IiP, (I le-I12 PM p2) 061;Z0244 ignature Print Name Date EHD 16-26 12/27/2012 2 CFO CLASS A CHECKLIST