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5AN _1 UAU U I N Envl'ronlmenfal FI-ea-11h uepaPfinent <br /> COUNTY <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit a: 1234 <br /> Issued in count.: Counts name <br /> Chocolate Chip Cookies With Walnuts <br /> saliv Baker <br /> 1?3 Cottage Food Lane <br /> Ai rswhere.CA 90—N\ <br /> Ingredients: Em iched flour(Vl1►eat flour.►nacin.reduced iron.tluanu ne. <br /> n►ononinate.tibotlav in and folic acid).butter uuilk.salt).chocolate clips <br /> (sugar.chocolate liquor.cocoa butter.butterfat ntnik). walnuts.suear.esu_, <br /> salt.arrtttc►al catulla extt'act,baku►s soda. <br /> Contains:Wheat.eggs,mill-.u,c.icab►uts <br /> Net\N t.3 uz.I`5.1 149sl <br /> Note:For the`Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Pse check what type of treatment is used to dispose of waste <br /> IYPublic 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 Department <br /> 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:V �`b�/t alr P �d f GI D1 .A-" ct <br /> ❑ Private Water Supply", Identify the source (well, spring, surface, etc.): l <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 /> 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 provide proof <br /> of completion of the California Food Handler course in lieu of the California Department of Public Health <br /> (CDPH)food processor course. <br /> For more information see CDPH website www.cdph.ca.gov/programs/Pages/fdbCoffageFood.aspx <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />