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SAN JOAQUIN <br /> Environmental Health Department <br />COUNTY -- <br />7. DeiiVOIN Limitation: Initial if you agree to abide by the following:L <br />I understand that I may accept orders and payments via the internet, mail or phone. However, all Class A'' and <br />"Class El" CFO products must be delivered gjLe_cli (in person) to the customer. The CFO products may not be <br />delivered via the United States Postal Service, UPS, FedEx, or using any other indirect delivery method as <br />deliveries are regulated by, and subject to, CDPH registration and state and federal requirements. <br />8. Owner's Statement: <br />I, <br />, agree to grant access to the local health department to <br />conduct an inspection of my cottage food operation (mark one) <br /> <br />; <br />Xt"Class A": In the event of a consumer lp "Class B": For regular annual facility inspections <br /> <br />complaint or reported food-borne illness and in the event of a consumer complaint or <br />food-borne illness <br />I, Liu I I t., <br />agree to notify the San Joaquin County Environmental <br />Health Department prior to modifying 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 />consigned, or given away. <br />9 la bla-( Jul le_Escli <br />14-- Owner's Signature Print Name Date <br />ELLIOTT ROAD DARN <br />Rusty Rentals & Baked Coeds <br />MADE IN A HOME KITCHEN <br />Permit tiPT0021966 <br />Issued in San Joaquin County <br />PEANUT BUTTER CHOCOLATE <br />CHIP SCONES <br />PEANUT BUTTER CHOCOLATE <br />CHIP SCONES <br />Ingredients: All purpose flour (bleached wheat flour. malted Barley flour. niacin, <br />reduced iron. asorhic acid, thiamin mononitrate). Cornstarch. Sugar. Hem <br />Cream(Neavy Cream. skim milk, polysorhate 80. carrageenan). Butter (pasturized <br />cream. natural flavors). Peanut Butler (Roasted Peanuts, Sugar. Molasses. fully <br />Hydrogenated Vegelahle Oils. Mono and Niglycet ides. Sall) Chocolate Chips (sugar, <br />Chocolate. Cocoa butter, nilklat, soy lecithin. natural flavors) Egg. Baking Powder, <br />Baking Soda. Sall <br />Contains: Meat. Milk. Eggs, Nuts <br />Net vit. 14.8 of (410.8 g) <br />ELLIOTT ELLIOTT ROAD BARN <br />1.4 MI 01 1.4 <br />Rusty Rentals & Baked Dods <br />MADE IN A HOME KITCHEN <br />Permit 010027966 <br />Issued in San Joaquin County <br />APPLE PIE <br />APPLE PIE <br />Ingredients: Apples. flour (bleached wheal flour, niacin, iron. thiamine <br />mononitrate, riboflavin, enzynes. folic acid), sugar, shortening (soybean oil, <br />fully hydrogenated palm oil, mono and diglycerides,1880 and citric acid, <br />natural and artificial flavor, beta carotene), salt (salt, calcium silicate. <br />dextrose, potassium iodide), cinnamon, nutmeg. butter (pasteurized cream, <br />natural flavors) <br />Contains: Wheal. Soy, FM <br />Net wt. 3Ib 5.5oz (I.52kg) <br />23216 N. Elliott Rd. <br />Scamps, CA 95220 <br />elliottroadbarn@gmail.com <br />23216 N. Elliott Rd. <br />fleampo. 55 95220 <br />elliottroadbarn@gmail.com <br />2 of 2