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SAN ,,J 0 A Q U IN Environmental Health Department <br /> - — <br /> COUNTY — <br /> Example: <br /> NUDE IN A HOME KITCHEN' <br /> Permil M: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90.1'XX <br /> Ingredients: Enriched flan(Wheat float niacin,reduced ima,thiamine. <br /> mononitrate,riboflavin and folic acid).butter(milk,sa1),chocolate clips <br /> (sugar.chocolate liquor,cocoa butter,butterfat(milk), walvium sugar,eggs, <br /> ,all.artificial vanilla extract.baking soda. <br /> Contains;Wheat,eggs,mflk4 soy,walnuts <br /> Net Wt.3 oz(85.049g) <br /> Note:For the-Issued in County'-Identify the jurisdiction(city/county)where you are obtaining approve/ <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 /> Name of Public Water System or Community Services District: CI- V aO Lodi <br /> ❑ Private Water Supply", Identify the source(well, spring, surface, etc.): <br /> Private Water Supply,Inidal Water QualftyResults <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 8 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: 00 <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 wabsite wmw,cduh.ca.aov/oroaramslPaaeslfdbCottaaeFood.asox <br /> 4 of <br /> EHD 16-27 6r2W17 CFO REGIPERMITTING FORM <br />