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Example: <br /> MADE IN A HOME 5ITCHE\' <br /> Permit#:: 1223445 <br /> Issued in county: Coun".name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90.1"\.X' <br /> Tna.ulimlc• r...iAm fln...I tun—,n....1 „ .M­m im.. ,h;....6,0 <br /> ntonouitmte,riboflavin and folic acid).butter(milk salt).chocolate chips <br /> (sugar,chocolate liquor,cocoa boner,butterfat(urilk), mahntts,sugar.eggs. <br /> salt.artificial vanilla ethuct,baking soda_ <br /> Contains:RLeat,eggs,mal:,soy,walnuts <br /> Net Wt.3 oz.(85,0498) <br /> n <br /> Note:For the'Issued in County'-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Plan7 <br /> check what tune of treatment is used to disnose 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_ Watpir Rniirrp- <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> P Name of Public Water System or Community Services District: M eF—STCe- } <br /> ❑ Private Water Supply', Identify the source(well, spring, surface, etc.):" <br /> Pdvate WaterSupply: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 /> M Klibefc Tec4 <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 <br /> . s..x:..r •c...... a.. �. ar... jurisdiction. <br /> CVVY o.VVeJJV1 CO-U.—.0- <br /> ....Var rr rVY Py166 LVYYr U.W .Vftw:ngop, <br /> Within 3 months of being approved to operate by the Environmental Health Department, please <br /> provide proof of completion of the California Food Handler course in lieu of the California Department <br /> of Public Health(CDPH)food processor course. <br /> For more information see CDPH website www.cdoh.ca.aov/programs/PaciesttdbCottaaeFood.aspx <br /> EHD 16-27 6112116 4 CFO REGIPERMITTING FORM <br />