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N ((1 A (�1 [ }�� Environmental Health Department <br /> "COUNTY................. <br /> Example: <br /> 1IADE I\A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Late <br /> Anywhere,CA 90.VCX <br /> Ingredients: Emiched flour(Wheat flour.uiacin,reduced iron.thiamine. <br /> mononitrate,riboflavin and folic acid),butter(n0k,salt).chocolate chips <br /> (sugar,chocolate liquor.cocoa butter,butterfat(milk), walnuts,sugar,eggs, <br /> salt,artificial vanilla extract,baling soda_ <br /> Contains:VVIteat,eggs,mill:,soy,walnuts <br /> -Net NN1 3 oz.(55.049g) <br /> Note:For the'Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> PI <br /> e check what type of treatment is used to dispose of waste <br /> 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: �1' H&tl Tv-6;,Cy GP% <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: V V K_ <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/Pages/fdbCottageFood.aspx <br /> 4 of 5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />