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SA N .10 A Q U IN Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permil If: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Balser <br /> 123 Cottage Food lave <br /> Anym9here.CA 90.VCX <br /> Ingredients: Enriched flour(Wheat flour.niacin.reduced iron,thiamine. <br /> mononitrate,riboflmin and folic acid),burner(milk,salt),chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk). walnuts,sugar,eggs. <br /> salt.artificial vanilla extract,baking soda. <br /> Contains:%Vheat,eggs,milk.soy,Walnuts <br /> Net Wt.3 oz(85.049g) <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 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 /> E4 Name of Public Water System or Community Services District: <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: YYA <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.asox <br /> 4 of 5 <br /> EHD 16-27 6/29/17 CFO REGIPERMrMNG FORM <br />