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agree to grant access to the local health <br />202.SPrint Name <br />EHD1M7S2»2Q23 5 CFO REG/PERfcurnNG FORM <br /> Nitrite Test (every 3 years*): <br />••Additional information may be required If food la prepared from a home with a private water euppiy - check with local Jurisdiction. <br /> A\w\ < <br />/ZepeJ*___t r------- <br />my cottage food operation (mark onei <br />'“Class A": In the event of a consumer <br />complaint or reported food-bome illness <br />11. Owner's Statement. <br />i. AAwxa <ji p <br />department to conduct an inspectfon of r <br />I <br />Date <br />® Initial If you agree to abide by the following: <br />lO. Delivery Limitation: Initial If you aoree to abide by th. following (W, <br />EiJkonnwoW O^.nZ.^pr^'^m^lng^y mamwl <br /> “Class B": For regular annual facility <br />xxira“umer <br />8. Food Processor Course: initial If you agree to abide by the following: <br />°f bTinB aPProved 10 op’rate •» the Environmental Health Department, please <br />of Publ^S p^S^rX^ Handler 10 lleU ,t’e Caltomla DeP“' <br />For mon, jnfcxmabon « COPH »WW.^KM.nw(pTOramWp,B^Mhc9ttmFw< Mm