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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sicehd.com <br /> O°I TACE FOOD OPERATIONS (CFO) <br /> REG ISTRATION/PERMITT[NC's RENEWAL FORM <br /> CFO Business Name: Owner Name: Date: <br /> CFO Physical Address: CFO City: CFO Zip: <br /> alni GAeD", AVE MANTEC,A 9.553_7 <br /> Website(If applicable): Telephone: <br /> vCur FWI��c�r�(` o nkPS fpm (il) tio2Z q982— <br /> I. <br /> 1. Cateoories: 0� <br /> X, "Class A" (Direct Sales Only)$125 ❑ "Class B" (Direct& Indirect Sales) $250 <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 ALLOWED. <br /> Only foods that are defined as"non-potentially hazardous" are approved for preparation by a Cottage Food <br /> Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br /> growth that could be a cause of food-borne illness. <br /> 3. Products: <br /> Provide a list of all products you are preparing. If preparing jams,jellies, or fruit butters include a list <br /> of ingredients (attach separate page if needed). <br /> Food List: <br /> Clirlton �P�� t r ) <br /> 4. Product Labeling: <br /> Attach two labels to this form for two of your CFO products (only one label is required if only one <br /> product is made). <br /> 5. Water Source: <br /> Please check what type of water source is being used at the CFO: <br /> ❑ City Water 06 Private Well` <br /> *If a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) <br /> EHD 16-296/29/2015 1 CFO REG/PERMITTING RENEWAL FORM <br />