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r <br /> Example: ~ <br /> MEADE IN A HOA'M KI'T'CHEN <br /> Permit#: 12345 <br /> Issued in county: County nate <br /> Chocolate Clip Cookies WithVraluuts <br /> sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90-,= <br /> Inc-edients: Emichrd flora'(Wheat flour,niacin,reduced iron,thianrine, <br /> monouitrate,riboflavin and folic acid);butter(lull},salt),chocolate chips <br /> (sugar,chocolate liquor,cocoa batter,butterfat(milk), walnuts,sugar,eggs, <br /> salt,artificial vanilla extract,bakiug socia. <br /> Contains:Wheat,eggs,Wilk,soy,walnuts <br /> Net Wt.3 oz.(85.0498) <br /> Note:For the"Issued in County'-Identify the jurisdiction(citylcounty)where you are obtaining approval. <br /> I � <br />'i 6. Disposal of Wastes <br /> t <br /> Please check what type of treatment is used to dispose of waste <br /> l <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 /> r <br /> 7. !!!later Source: <br /> I . <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> ❑ Larne of Public Water System or Community Services District: C, LT <br /> ❑ Private 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 /> ❑ Bacteriological Test(quarterly"): <br /> ❑ 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 local jurisdiction. <br /> S. 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.cd;3h.ca.gov/programs/PageslfdbCottageFood.asp <br /> EHE 16-27 116/2614 3 CM REGIPERMITTiNG FORM <br /> w <br />