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SA N ]O A Q U I N Environmental Health Department <br /> C OU N TY _.... <br /> Example: <br /> XL1DE IN A HONE KITCHEN <br /> Permit#: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Line <br /> :3ulvvhere,CA 90;1 , <br /> Ingredients: Enriched flour(Wheat flour.niacin,reduced iron.thiamine, <br /> mononitrate,riboflavin and folic acid).butter(mill:,salt).chocolate chips <br /> (sugar.chocolate liquor.cocoa hatter,butterfat(milk), Nvahmts,sugar,eggs, <br /> salt.artificial vanilla extract,baking soda. <br /> Contains:NVheat,eggs,mill: 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 /> Ple a check what type of treatment is used to dispose of waste <br /> 7ublic 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 boLC�,I ►t/x) J� I / <br /> Name of Public Water System or Community Services District: C1 t 0 ro Vl.+ LI <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: <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.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />