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SAN JOAQUIN <br />7. Owner's Staterniffai <br />I, 4it <br />c46-c1l0• <br />Environmental Health Department <br />, now, to grant antlers to the krAl health department to <br />lood-oiveralign (mark one) <br />t9.."'Cless A-. In the event of a consumer <br />oomplaire or reported food-home illness <br />[1 "Class Fr: For regular annual facility inspections <br />and in the event of a consumer complaint or <br />food-borne illness <br />I. 11 k , agree to notify the San Joaquin County Environmental <br />Health Department prior id\nodifying 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 />consigned, or given away. <br />L'L <br />7 4 ly/i1as2,1/.._ 1(a <br />Owner's Si6natumj Print Name Date <br />END 18-29 6127 /22 <br />2 <br />CFO REGIPERMITTING RENEWAL FORM