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Example: <br /> NL,DE M A HOl\IE KITCHEN <br /> Permit#: 12345 <br /> Issued In county: Countv name <br /> Chocolate Chip Cookies With R%ahmts <br /> Sally Baker <br /> 133 Cottage Food Lane <br /> AnNivhere,CA 901"1-1 <br /> Ingredients: Enriched tlour('Mieat flour,niacin reduced iron.thiamine, <br /> mouonivate,riboflavin and folic acid).butter(Uuilk.salt).chocolate chips <br /> (sugar,chocolate liquor.cocoa butter.butterfat(milk), walnuts.sugar,eggs. <br /> salt.artificial vanilla extract.bakiug soda. <br /> Contains:NN-heat,eggs,milk,soy,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 /> rS 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: f <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 /> ❑ Nitrate 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 <br /> provide proof of completion of the required California Department of Public Health (CDPH)food <br /> processor course. <br /> For more information see CDPH website www.cdph.ca.gov/programs/PagesKdbCottaaeFood.aspx <br /> EHD 16-27 12/27/2012 3 CFO REG/PERMITTING FORM <br />