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SA Nil 0 A O I I I AI Environmental Health Department <br /> COUNTY— <br /> Example:Example: <br /> %LADE IN A HOi41E KITCHEN <br /> Permit#: 12315 <br /> Issued in couniy. County name <br /> Cliocolnte CNP Cookies XVith lVabmts <br /> Sally Ilaker <br /> 12"Cottage Food Lwe <br /> An)lvhere.CA 90.1-x'1 <br /> Ingredients: Enriched flea(Wheat flan.nincin.reduced iron,thinuune. <br /> niononitmte,riboflavin and folic acid).Neter(null:.&ah),chocolate clips <br /> (sumo.chocolate li(iom.cocoa butter.bunerfnt(nulk), walnuts.sugir.eggs. <br /> salt,mtificial sm ulla extract.biking sodas . <br /> Contains:\Bean,eggs,milk soy,walnuts <br /> Net W4 3 oz(&S,e49g) <br /> Note:For the-Issued in County'-Identify the jurisdiction(cityPoounty)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> 0 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: C4L UJ}1T <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.ra.aov/orolm m MaaeslfdbCottaaeFood.asox <br /> 4 of <br /> EHD te-276f29117 CFO REGIPERMrTTING FORM <br />