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SAN910 A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> NLADE Ilia HOME KITCHEN <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Cirip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> An3ivhere.CA 90% X <br /> Ingredients: Enriched flotu(Rlreat floor.niacin.reduced iron.tlriamine. <br /> mononitrate,riboflavin and folic acid).butter(inilk.salt).chocolate clips <br /> (sugar.chocolate liquor.cocoa butter.butterfat(null:). walnuts.sugar.eggs. <br /> salt.artificial vanilla extract.baking soda. <br /> Contains:AN-heat,eggs,milk,soy,walnuts <br /> Net\Vt.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 /> Plea a 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: �� C4 Truck <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: <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/fdbCottageFood.asox <br /> 4of5 <br /> CFO REG/PERMITTING FORM <br /> EHD 16-27 6/29/17 <br />