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AN 10 A Q U N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE IN a HOME KIT(T-IEN <br /> Permit=: 12345 <br /> Issued in county: Counts name <br /> Chocolate Chip Cookies With 41'1lnuts <br /> Sall),Baker <br /> 123 Comm Food Lane <br /> Ainivhere.CA 90. XX <br /> Iw-redients: Enriched flour(W'heat flout,niacin.reduced iron.thiamine, <br /> mononitrate,riboflaNrin and folic acid).butter(twill:,salt).chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk), walnuts.sugar.eggs. <br /> salt.artificial vanilla extract.baking soda. <br /> Contains:Wheat.eggs,mill:,say,«walnuts <br /> Net Wt.3 oz.(8i.0490 <br /> Note.For the`Issued in County"-Identify the jurisdiction(city/county) where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please heck what type of treatment is used to dispose of waste <br /> LO.-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 /> lame of Public Water System or Community Services District: C4 L-9 �►"�QAeca <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.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />