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SANJ O A Q U ! N Environmental Health Department <br /> C_7 l_) N T'Y­w <br /> Example: <br /> — NIAI41 IN A HOME:KITCHEN <br /> Permit#: 12345 <br /> Issued In county: County n:uue <br /> Chocolate Chip Cookies With NValuuts <br /> `wally Baker <br /> 133 Cottage Food Lane <br /> 1mlvllere.CA 9UN-N-N <br /> I I <br /> Ingredients: Eiutched flour(Wheat flour,uiaciu.reduced iron.t1waline. <br /> urcmouitrate,riboflivin and folic acid).butter unilk,salt),chocolate chips <br /> (sugar.chocolate liquor.cocoa butter,butterfat(milk). walnuts.su.gar.eggs. <br /> salt.artificial Vanilla extract,baking soda. <br /> Contains:Wheat,eggs,milk,sod,walnuts <br /> Net NN"t.3 oz.(85.049g) <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 V Private Septic System <br /> !n the crcnt of septic system failure or plumbing problem,you are required to notify San Joaquin County Enr,ircnmcnt-n! Hcn!th Department <br /> immcrliatohi <br /> `0 i 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 /> P99 <br /> —1PrivateWater Supply**, Identify the source (well, spring, surface, etc.): <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 /> —, <br /> U i�iii iic i vai(evci y 3 ycai 6'j- <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: f� <br /> Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br /> of compietion of the Caiifornia Food Handier Course in iieu of the California Department of Public Health <br /> (uuF t-i)tooa processor course. <br /> For more information see CDPH website www.edoh.ca.ciov/programs/Paues/fdbCottacieFood.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />