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Example: <br /> MADE IN A HOME KITCHEN <br /> Perrot#: 12345 <br /> '-Issued In county:County name <br /> Chocolate Chip Cookies With Walnuts <br /> Selly Balker <br /> 123 Cottage Food La e <br /> Anywhere.GA 90XXX <br /> Ingrodkara:...Enriched flour(Wheat floor,niacin,reduced iron,thiamine. <br /> wa sooioate;ribotlavmaod folic acid),butter(milk,salt),chocolate chips <br /> (sups,chocolate lguar,cocoa butter,butterfat(milk), walnuts,sugar,eggs, <br /> salt,artificial vairills atrucL baking soda. <br /> -Costa W:When,egm milk.soy,walsats <br /> Net WL 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 We 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 /> LXW <br /> Lope <br /> ❑ Private Water Supply", Identify the source (well,spring, surface,etc.): <br /> Private Water Supply:Initial Water Quality Results <br /> Check taxes 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 tJomtation may be required'f food is prepared from a tame with a private water supply-check with local jurisdiction. <br /> 8. Food.Protcessor 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 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.edth.eaaov/oroarams/PaaeslfdbCottaneFood.asox <br /> EHD 16-272/3117 4 CFO REG/PERMITTING FORM <br />