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SA N J O A Q U I N Environmental Health Department <br /> COUNTY— <br /> Example: <br /> \LADE IN.A HOME KITCHEN' <br /> Permit a: 1245 <br /> Issued In county: Couny name - <br /> CLocolate Chip Cookies With walums <br /> Sally Bake <br /> 12?Cottage Ford Line <br /> Anlvhere.CA 90:0,X <br /> Ingredients: Enriched flotu(Alreat floor,minciu.reduced iron duauune. <br /> rnononinate,riboilwin and Colic acid).inmer Inulk solid.chocolate clops <br /> (sugar,chocolate liquor.cocoa boner.bunerfat(Hulk). «alums.Siler,eggs. <br /> salt.artificial squilla exmct,baking soda. <br /> Contains:Wheat.eggs,milk soy.nalnuts <br /> Net wL 3 0t.(85.049g) <br /> Note:For the"Issued in County'-ldentiry thejud8dicdon(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 /> 14YPublic 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: t:K lure M UK(6 r(J <br /> ❑ Private Water Supply", Identify the source(well,spring,surface,etc.): Y <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 8 food is prepared from a home Will a private water supply—check with local jurisdiction./n. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: e/l <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.mqovlproorams/PagestidbConageFood.asox <br /> 4 of 5 <br /> EHD 16-27629/17 CFO REG/PERMriTING FORM <br />