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SA N J O A Q U I N Environmental Health Department <br /> COUNTY-- <br /> Example: <br /> MADF. IN,1 HOME F:ITC11EN <br /> Permit#: 12345 <br /> Issued in count.: Counh name <br /> Chocolate Chip Cookies With Walnuts <br /> Salle Baker <br /> 12?Cortase Food Lane <br /> Ain-where.CA 90XXX <br /> Ingredients: Enriched flour(Mleat flour.niacin.reduced iron.thiauune. <br /> mononitrate.tiboflacin and folic acid).butter(milk.salt).chocolate chips <br /> (sugar.chocolate liquor.cocoa butter.butterfat(milk). INminuts.swear,e22s. <br /> salt.artificial cauilla extract,baking soda. <br /> Contain+:Wheat,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 /> ❑ Public Sewer Service I�Ifrivate 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 /> n Name of Public Water System or Community Services District: Yy A4-(*-rrl 11 <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: 4B <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.edph.ca.gov/programs/Panes/fdbCottaaeFood.aspx <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />