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SANJ O A Q U I N Environmental Health Department <br /> C_ C>I,1i\; <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With\Walnut. <br /> Sally Baker <br /> 123 C'ottaee Food Lauc <br /> Anywhere.CA 90SCC <br /> Ingredients: Enriched flour(«"heat!lour.niacin.reduced iron.thiamine. <br /> mononinate.riboflavin and folic acid).butter owlk.salt),chocolate chips <br /> (sugar.chocolate liquor,cocoa butter.butterfat(milk). walnuts.sugar.esss. <br /> salt.artificial vanilla extract.bakins soda. <br /> Contains:NNIeat,eggs,mill:.soy,walnuts <br /> Net NN't.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 /> 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: a„t� Q t �S�YI�E <br /> F1PrivateWater 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 provide proof <br /> of completion of the California FooHandler course in lieu of the California Department of Public Health <br /> (CDPH)food processor course. - )ImAl4 oyvy)l olJ <br /> For more information see CDPH website www.cdph.ca.ciov/programs/Pages/fdbCottageFood.aspx <br /> 4 of 5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />