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Date: <br />CFO Zip: <br />ST:3 <br />RECi*e6UIN <br />Y <br />5 here. <br />MAR 1 4 2025 <br />grows <br /> <br />Environmental Health Department <br />C)10,0aS-V1L-1 <br />PR 054 2c2.C4 <br />ENVIRONMENTAL HEANTTAGE FOOD OPERATIONS (CFO) <br />pERmrrisEFREERSTRATION/PERMITTING RENEWAL FORM <br />CFO Business Name: Owner Name: <br />allot <br />CFO Physical Address: CFO City: <br />C krA-k NT (-1- (-I St- C <br />Website (If applicable): Telephone: <br />B on.)D <br />Categories: <br />4_ "Class A" (Direct Sales Only) $186 "Class B" (Direct & Indirect Sales) $486 <br />2. Prohibited Items: Initial if you agree to abide by the following: <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT A LOWED. Only <br />foods that are defined as "non-potentially hazardous" are approved for preparation by a Cottage Food Operation. <br />These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a <br />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 of <br />ingredients (attach separate page if needed). <br />Food List: <br />OX' , S <br />C_Vvo c C <br />r0\- kp S <br />trAnciVi) <br /> <br />Rt ' <br />A14R <br />7 2025 <br />''(174',?1;): <br /> <br />Product Labeling: <br />Attach two labels to this form for two of your CFO products (only one label is required if only one product is <br />made). <br />Water Source: <br />Please check what type of water source is being used at the CFO: <br />''City Water El Private Well* <br />*If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br />Food Processor Course: <br />Attach food handler certification for owner and each individual that were not submitted with initial application <br />(including family members and/or employees). <br />1868 E. Hazelton Avenue I Stockton. California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com