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P (<^Soq Environmental Health Department “Class A” (Direct Sales Only) $186 □ “Class B" (Direct & Indirect Sales) $486 Sourdough Bread *lf a private well, attach all updated water sample results (including quarterly bacteria and Nitrate results.) 1. Categories: KI Owner Name: Allison Gerdes CFO City: Tracy_______ Telephone: 350-233-1749 CFO Business Name: Rockin Robin Sourdough CFO Physical Address: 28200 S Bird Rd_______________ Website (If applicable): Facebook.com/RockinRobinSourdough SAN JOAQUIN ------COUNTY------- Grcafncf^ grows here. 5. Water Source: Please check what type of water source is being used at the CFO: □ City Water Private Well* COTTAGE FOOD OPERATIONS (CFO) REGISTRATION/PERMITTING RENEWAL FORM 3. Products: Provide a list of all products you are preparing. If preparing jams, jellies, or fruit butters include a list of ingredients (attach separate page if needed). Food List: 4. Product Labeling: Attach two labels to this form for two of your CFO products (only one label is required if only one product is Date: . . CFO Zip: 95304 2- Prohibited Items: Initial if you agree to abide by the following: Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. Only foods that are defined as “non-potentially hazardous” are approved for preparation by a Cottage Food Operation. These foods include items that do not require refrigeration to keep them safe from bacterial growth that could be a cause of food-borne illness. 6. Food Processor Course: Attach food handler certification for owner and each individual that were not submitted with initial application (including family members and/or employees). 1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjcehd.com