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SAN ) O A Q U I N Environmental Health Department <br /> ---C O U N Y— <br /> Example: <br /> \L-1DE INA HO-NIE KITCHEN' <br /> Permit=: 12345 <br /> Issued in count.: Counth name <br /> Chocolate Chip Cookies\\uh\\alnut. <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Ain-chere.CA 90X.\.\ <br /> Ingredlents: Emiched flour i\\'heat flour,niacin.reduced iron.thiamine. <br /> ntononivate.riboflavin and folic acid).butter innik,salt).chocolate claps <br /> (sugar.chocolate liquor.cocoa butter,butterfat(milk). walnuts,sugar,egg.. <br /> salt.artificial Manilla extract.baking soda. <br /> Contains:\\heat.eggs,milk,soy.scalnuts <br /> \et Wil.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 /> ZPublic 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 /> Jame of Public Water System or Community Services District: 60WA" W <br /> ❑ Private Water Supply**, Identify the source (well, spring, surface, etc.).- <br /> Private <br /> tc.):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: 9-1V <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.cdph.ca.gov/programs/Pages/fdbCoftaneFood.aspx <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />