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SAN JOAQUIN <br />—COU lam. <br />7. Owner's Statement: <br />Environmental Health Department <br />I,OJ IA � I >° t- d6 --E C , agree to grant access to the local health department to <br />conduct an inspection of my cottage food operation (mark one) <br />"Class A": In the event of a consumer ❑ "Class B": For regular annual facility inspections <br />complaint or reported food -borne illness and in the event of a consumer complaint or <br />food -borne illness <br />I, VU I I*ei "e I e L I , 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 />Print Name <br />€LUOTT ROAD BARN <br />Rusty Rentals & Baked Coods <br />MADE IN A HOME KITCHEN <br />Permit 016027966 <br />Issued in San Joaquin County <br />23216 N. Elliott Rd. <br />&cameo, CR 95220 <br />elliottroodbarn®gmail.com <br />LEMON SCONES <br />LEMON SCONES <br />Ingredients: All purpose flour (bleached wheal If malted barley flour. niacin. <br />reduced iron, asonbic acid, thiamin mononitrate, riboflavin, folic acid, asorb ic acid <br />added as a dough conditioner) Butter (pasteurized cream and natural flavors) Heavy <br />Whipping Cream (cream), Powdered Sugar (cane sugar, cornstarch) fresh Lemons. <br />Egg, Pure vanilla. Baking Powder, Sall (sail, calcium silicate, dextrose, potassium <br />iodide) Baking soda (sodium bicarbonate) <br />Contains: wheat, milk, egg <br />Nei VVI. 1001 (283.68) <br />EHD 16-296/27/22 2 CFO REG/PERMITTING RENEWAL FORM <br />