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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. ❑ 13. All food ingredients used in the CFO products are from an approved source. ❑ 14. Potable water shall be used for hand washing, ware washing and as an ingredient. ❑ 15. Is your water source a private well? ❑ X a. If YES, have you completed testing for bacteria and nitrate? ❑ ❑ 16. Is your water source a public water system or community services district? El 1 a. YES, what is the name of the system or district? L�n4f n Cottn'1 U 1.IX W oc �q During the preparation, packaging or handling of CFO products: Yes No 17. Domestic activities such as family meal preparation, dishwashing, clothes washing or to ( ❑ ironing, kitchen cleaning or guest entertainment are excluded from the kitchen. jo 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. ❑ Labeling Requirements: Yes No 21. A copy of the label has been submitted to this Department for review and approval. X ❑ 22. 1 have attached a sample label. X ❑ 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 completed and submitted by: jvw�1 `"",e— Mira °I /2-L Sipnatu 0)i Print Name I bate EHD 16-26 12/27/2012 2 CFO CLASS A CHECKLIST