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SA N yJ O A Q U I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HOME HITCHED <br /> Permit»: 12345 <br /> Issued in county: County name <br /> Chocolate Clip Coolies With Walnuts <br /> Sally Baker <br /> 123 Cortage Food Lam <br /> Anysvbere.CA 90X.-XX <br /> Ingredients: Enriched floor(li'heat flour-niacin.reduced iron.thiamine. <br /> mououitrate.riboflavin and folic acid).inner Oullk.salt).chocolate clips <br /> (sugar,chocolate liquor,cocoa butter,bunerfat(mink), walnuts.sugar,eggs. <br /> salt.mlificial vanilla extract.baking soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3 oz(85.049g) <br /> Note:For the"Issued in County"-Identify the jurisdiction(cityleounty)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> 1APublic 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: ci ,� & <br /> El Private Water Supply", Identify the source(well, spring, surface,etc.):� J� <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 tome with a private water supply—check with local jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following:M <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.cdoh.ca-amloroaramslPamWfdbcottaaeFood.asox <br /> 4 of <br /> EHD 16-27 6/29117 CFO REG/PERMrrTING FORM <br />