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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. I Jt EJ/ 13. All food ingredients used in the CFO products are from an approved source. ice/ El u 14. Potable water shall be used for hand washing, ware washing and as an ingredient. ❑ 15. Is your water source a private well? ❑ 0 a.lf YES, have you completed testing for bacteria and nitrate? L1 ❑ 16. Is your water source a public water system or community services district? u ❑ a.If YES, what is the name of the system or district? 5000-00 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. 2' ❑ 19. Smoking is excluded. V ❑ 20. Any person with a contagious illness shall refrain from work in the CFO. Er ❑ Labeling Requirements: Yes No 21. A copy of the label has been submitted to this Department for review and approval. [ r ❑ 22. 1 have attached a sample label. �L'_I ❑ By signing below u ar certifying that you meet the requirements of the California Homemade Food Act, Ata 1616 (Gatto), as it pert ins to a "Class A" Cottage Food Operation. Prior to making any changes, I acknowledge that I must notify San Joaquin Count. Environmental Health Department of any intended changes to the above statement. Cottage Food Qperator Checklist completed and submitted by: V ��1� 1?.YY'1S(/1 CIG 17. �DZI U Print Nam Date EHD 16-261212712012 2 CFO CLASS A CHECKLIST