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SANJOAQUIN <br />—COUNTY <br />Environmental Health Department <br />DeliverV Limitation: Initial if you agree to abide by the following: L6 <br />I understand that I may accept orders and payments via the internet, mail or phone. However, all "Class A" and <br />"Class B" CFO products must be delivered directly (in person) to the customer. The CFO products may not be <br />delivered via the United States Postal Service, UPS, FedEx, or using any other indirect delivery method as <br />deliveries are regulated by, and subject to, CDPH registration and state and federal requirements. <br />8. Owner's Statement: <br />I, �V`� v 1U" \�X �\M , agree to grant access to the local health department to <br />conduct an Inspection of my cottage food operation (mark one) <br />(_19'Class A": In the event of a consumer ❑ "Class B": For regular annual facility inspections <br />L complaint or reported food -borne illness and in the event of a consumer complaint or <br />food -borne illness <br />I, �4 ' ww , agree to notify the San Joaquin County Environmental <br />Health Department prior to modifying my food list, type of operation, and/or method of selling, distributing, or <br />otherwise providing,my CFO products to the consumer or retailers, regardless of whether the product is sold, <br />c sl ed, or giveaway. <br />Owner's <br />0�_ 'NtYkM IzI�bII-, <br />Print Name <br />MADE IN A HOME <br />KITCHEN <br />PERMIT #0027188 <br />ISSUED IN: SAN JOAQUIN COUNTY <br />laticia Duenas <br />Fscalon. Ca 95320 <br />ELDERBERRY <br />ECHINACEA TEA <br />Ingredirnls; elderberry, <br />echinacca, purpureu herb h3 <br />root, peppermint, yarrow, <br />ginger, chamomile <br />Dilectious: Add I 'PRS in I cup bol <br />water for 10-15 minutes <br />14 1.5 oz fA2,52 g) <br />MADE IN A HOME <br />KI1 CHEN <br />Pl IINIII #002 1188 <br />ISS( 11) IS: S%S 101,0ldNt Ol NIN <br />Onlon & 11erb Neusont", <br />I alklo Duenas <br />I Nc nlon. C +\ 96 I I D <br />Inquannn{.; m1m ea onNm. unl�m q,nnuln. <br />,emr,, ala ema�,. ual <br />Nal %1. 1." m Vo 99-11 <br />EHD 16-296/27/22 2 CFO REG/PERMITTING RENEWAL FORM <br />