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Date 1>ignature <br />CFO REG/PERMFTTING FORMEHD 16-27 6/29/2023 5 <br />□ Nitrite Test (every 3 years*): <br />“Additional Information may be required if food is prepared from a home with a private water supply - check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following:------ <br />of Public Health (CDPH) food processor course. <br />For more information see CDPH website www.cdph.^.flQv/proqram^aqes/fdbCQttageFQod.as^ <br />9 Employee- ,nitial if y°u agree to abide by the followin9: — <br />consumers. <br />11. Ovw <br />l,_x_ departmei <br />“r lass A”: In the event of a consumer <br />cX“ °r reported food-borne "lness <br />10 DPliverv Limitation: lniUal if a9ree tO abide by t,,e fO"°Win9- <br />Vt ’ a9ree t0 notifythe San Joacluin County <br />Department prior to modifying my food list, type of operation, and/or method <br />EnVlHOna distributing, or otherwise providing my CFO products to the consumer or retailers, <br />°f Adless of whether the product is sold, consigned, or given away. <br />Print Nanie <br />r’s Statement: <br />7 ■ a9ree to 9rant access to the local health <br />inspection of my cottagTtood operation (mark one) <br />□ “Class B”: For regular annual facility <br />inspections and in the event of a consumer <br />complaint or food-bome