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Food Preparation Requirements(includes packaging and handling): Yes No 11. Hand washing is required immediately prior to handling foods and after engaging in any activity that contaminates the hands such as after using the toilet, coughing or . ❑ sneezing,eating or smoking. 12. Warm water, hand soap and clean towels are available for hand washing. B ❑ 13. All food ingredients used in the CFO products are from an approved source. Xr ❑ 14. Potable water shall be used for hand washing, ware washing and as an ingredient. ❑ ❑ 15. Is your water source a private well? ❑ rg a.If YES, have you completed testing for bacteria and nitrate? ❑ ❑ 16. Is your water source a public water system or community services district? ❑ a.If YES,what is the name of the system or district? During the preparation,packaging or handling of CFO products: Yes No 17. Domestic activities such as family meal preparation, dishwashing,clothes washing or ❑ ironing,kitchen cleaning or guest entertainment are excluded from the kitchen. 18. Infants,small children, or pets are excluded from the kitchen. ❑ 19. Smoking is excluded. ❑ 20. Any person with a contagious illness shall refrain from work in the CFO. 16 ❑ Labeling Requirements: Yes No 21. A copy of the label has been submitted to this Department for review and approval. Iy ❑ 22. 1 have attached a sample label. 1�r ❑ By signing below you are certifying that you meet the requirements of the California Homemade Food Act, AB 1616- (Gatto), as it pertains to a"Class A"Cottage Food Operation. Prior to making any changes, I acknowledge that I must notify San Joaquin County Environmental Health Department of any intended changes to the above statement. - Cottage Food Operat eckli t completed and submitted by: Q Aliyw�v��on l9 2� • Zo tgnature Print Name Date EHD 16-26122742012 2 CFO CLASS A CHECKLIST