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Example: <br /> MADE IS:,HOME KITCHEN <br /> Permit k: 12345 <br /> Issued in couniv: Comrtc name <br /> Chocolate Chip Cookies�%idu NN'111111t, <br /> Salto Baker <br /> 123 Cottage Food Lane <br /> .Aimvlrem CA 90SST <br /> Ingredients: Enhched Flour(\A heat flow,macer reduced ion.thiamine. <br /> mmrouitmre,riboflavin and folic acid).batter(milk.salt),chocolate claps <br /> (auear.chocolate liquor,cocoa butter.butterfat(milk). wab uts,sugar,eggs. <br /> salt_artificial varalla extract.baking soda. <br /> Contains:NN heat,eggs,milk,soy,walnuts <br /> Net NN t.3 oz.(85.049-) <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 /> Q 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 /> dName of Public Water System or Community Services District 6,�eilsn <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 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 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.cdph.ca.aov/proamms/Paaes/fdbCottaaeFood.aspx <br /> EHD 1627 2/3/17 4 CFO REGIPERMnTING FORM <br />