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Environmental Health Department <br /> W .IJOAQUIN <br /> COUNTY— <br /> Example: <br /> \UDE IN A I-10\9E KITCHEN <br /> Permit 1234., <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Coua,-e Food Luce <br /> Ans�clnere.CA 90.\.\.\ <br /> Ingredients: Enriched flour(Wheat flow,niacin.reduced iron,thiamine, <br /> mononilmie.riboflavin and Colic acid).butter(utilk,silt).chocolate chips <br /> (sugar,chocolate liquor,cocoa butler,buvedal(mill:), waluuts.sugar.eggs. <br /> salt.artificial vanilla exlmct.baking soda. <br /> Contains:N1110,11,eggs.nnilk,Sec,wainuls <br /> \el N11.3 oz.(8,,.1149-) <br /> Note:For the"Issued in County'-Identity 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 /> XPublic 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: 'fit O,Cu a�er <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. 1c <br /> 8. Food Processor Course: Initial if you agree to abide by the following: J•b <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.aspz <br /> 4 of 5 <br /> EHD 16-276/29/17 CFO REG/PERMITTING FORM <br />