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SA NA O A Q I I I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit 4: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With NValaats <br /> Sally Baker <br /> 123 Connie Food Lame <br /> Atpzsltere.CA 903—N' <br /> Ingredients: Enriched flour(\%%eai flour.niacin,reduced iron.thiamine. <br /> mononitrate,riboilmin and folic acid).butter(nrilk.stilt).chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(rink). %\mints,sugar.eggs. <br /> salt,artificial Amnilln extract,baking soda. <br /> Contains:Wheat.eggs,milk,soy,walnuts <br /> Net Wt.3 oz(85.0498) <br /> Note:For the'Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please 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 Heath Department <br /> immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) 1 <br /> 9Private <br /> Name of Public Water System or Community Services District: G}?�7p f 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 R <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: 56 - <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.edph.r .gov/proarams/PagestfdbCottoneFood.aspx <br /> 4 of 5 <br /> EHD 1&270/29117 CFO REG/PERMrTTING FORM <br />