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SANi o n P U I N Environmental Health Department <br /> Example: <br /> N1ADE IN A HOME KI CCHEN <br /> Permit#: 12345 <br /> Swed in count: County name <br /> Chocolate Clip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere.CA 90XVX <br /> Ingredients: Enriched flout(Wheat flout,uiacitr,reduced iron.thiamine. <br /> monouurate.ribofla%tin and folic acid).butter(mil IL- salt).chocolate clips <br /> t sugar.chocolate liquor.cocoa butter,butterfat(ruilk). nwalmtits.sugar.eggs. <br /> ,alt,artificial vanilla extract.baking soda. <br /> Contaln%:\\Leat,eggs,milk,soy,walnuts <br /> Net Wil.3 oz.(&5,0.19g) <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 Department <br /> immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> O'Name of Public Water System or Community Services District: <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 he required A food is prepared from a home with a private mater 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/fdbCottageFood.aspx <br /> EHD 16-27 6/29117 CFO REG/PERMITT ING FORM <br />