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SA I` ,Nd 0 A Q U I N Environmental Health Department <br /> —COUNTY-- <br /> Example: <br /> NUDE LN A HOAiE KITCHEN <br /> Permit k: 12345 <br /> Issued in county: County name <br /> Chocolate Ciup Cookies With R'ahnns <br /> Silly Baker <br /> 123 Cottage Food Lute <br /> Armvhem CA 9015% <br /> Ingredients: Enriched flour(Rgaeat floor.niacia.reduced von,duamme. <br /> naonenitmte.riboflavin and folic acid),butter(milk,salt).chocolate chips <br /> (swear,chocolate liquor,cocoa batter,butterfat(mill'), rvahmts.sugar,eggs <br /> t.u . <br /> saltificial t wifla ex-tract.baldug soda. " <br /> Contains:Wheat,eggs,mig:,soy,walnuts <br /> ret Wt.3 oz.(85.0498) <br /> Note.For the"Issued in County'-Identify thejurisdiction(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 immedivent of septic system failure or plumbing problem,you are required to notify San Joaquin County Environmental Health Departrnant <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: Tr�v^Tata 416' n <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 /> *(Tesfing 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: ` � <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 webste www.cdph.w.aov/omummsMagesMdbCoftaeFood.asox <br /> EHD 16-27 6/29/17 4 of 5 <br /> CFO REG/PERMITTING FORM <br />