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Example: <br /> MADE In A HOME KITCHEN <br /> Permit 4: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Coolies With Walnuts <br /> Sully Baker <br /> 123 Cottage Food Cane <br /> Anywhere.CA 9OXXX <br /> Ingredients: Enriched flour(Wheat Flour:niacin,reduced iron.thiamine, <br /> mouonunte,riboflavin and folic ncid).butter(nag;,salt),chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk). walnuts.sugar.eggs. <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:wheal,eggs,mill:,soy,uminuts <br /> Net W1.3 oz(85.049g) <br /> o L For the"Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> ;PIeKecheck what type of treatment is used to dispose of waste <br /> blic 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 <br /> Department 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 Communfty Services District: g e bl,iM r <br /> Private Water Supply", Identify the source(well, spring, surface, etc.): <br /> Private Water Supply: IniBal 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 <br /> provide proof of completion of the Califomia Food Handler course in lieu of the California Department <br /> of Public Health(CDPH)food processor course. <br /> For more Information see CDPH webstte www.cdoh.ea.aovloruaromstPaaeslfdbCottaaefood.asox <br /> EHD 16-27 629/2015 4 CFO REGIPERMnTING FORM <br />