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Date - Print Name Owner's Signature El Nitrite Test (every 3 years*): **Additional information may be required if food is prepared from a home with a private water supply — check with local jurisdiction. Food Processor Course: Initial if you agree to abide by the following: Within 3 months of being approved to operate by the Environmental Health Department, please provide proof of completion of the California Food Handler course in lieu of the California Department of Public Health (CDPH) food processor course. For more information see CDPH website www.cdph.ca.ciov/programs/Pacies/fdbCottacieFood.aspx Employee: Initial if you agree to abide by the following: I understand that I may not have more than one full-time equivalent cottage food employee, not including a family member or household member of the cottage food operator, working within the registered or permitted area of a private home where the cottage food operator resides and where cottage food products are prepared or packaged for direct, indirect, or direct and indirect sale to consumers. Delivery Limitation: Initial if you agree to abide by the following: I understand that I may accept orders and payments via the internet, mail or phone. Direct and Indirect sales may be fulfilled in person, via mail delivery, or using any other third-party delivery service throughout the state of California only. Owner's Statement: I, rEira 1l-b9u - CY)o\ty-Llijy1 , agree to grant access to the local health department to conduct an inspection of my cottage food operation (mark one) ra "Class A": In the event of a consumer complaint or reported food-borne illness [i] "Class B": For regular annual facility inspections and in the event of a consumer complaint or food-borne I, \.) kS ./C0\- 0\9\.) .C.Y)0k0(1.6 y,lagree to notify the San Joaquin County Environmental Health Department prior to modtlying my food list, type of operation, and/or method of selling, distributing, or otherwise providing my CFO products to the consumer or retailers, regardless of whether the product is sold, consigned, or given away. EHD 16-27 6/29/2023 CEO REG/PERMITTINIG FORM 5