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Example: <br /> MADE IN A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 9OXXX <br /> Ingredients: Enriched flour(Wheat flour,niacin,reduced iron,thiamine, <br /> mononitrate,riboflaviu and folic acid),butter(milk,salt),chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk), walnuts,sugar,eggs, <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3 oz.(85.0498) <br /> Note:For the'Issued in County'-Identify the jurisdiction(city/county)where you are obtaining approval <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> ❑ Public Sewer Service Private Septic System <br /> In the event of septic system failure or plumbing problem,you are required to notify San Joaquin County Environmental Health <br /> Department immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> ❑ Name of Public Water System or Community Services District: <br /> []15'rivate Water Supply**, Identify the source (well, spring, surface, etc.): <br /> Private Water Supply:Initial Water Quality Results <br /> Check boxes below if initial water testing has been completed. <br /> All testing must be done at a State Certified Laboratory. Either attach lab results or provide name of lab, date& <br /> results in space provided next to type of test. <br /> *(Testing frequency for transient Non-Community Water Systems after initial testing) <br /> Lj Bacteriological Test(quarterly*): <br /> u Nitrate Test(yearly*): <br /> Nitrite Test(every 3 years*): <br /> "`Additional information may be required if food is prepared from a home with a private water supply—check with locaijudsdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: <br /> Within 3 months of being approved to operate by the Environmental Health Department, please <br /> provide proof of completion of the required California Department of Public Health (CDPH)food <br /> processor course. <br /> For more information see CDPH website www.cdDh.ca.aovioroclrams/Panes/fdbCottageFood.asox <br /> EHD 16-271/0/2014 3 CFO REG/PERMITTING FORM <br />