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SANJ O A Q U I N Environmental Health Department <br /> Example: <br /> MADE INA HOME KITCHEN <br /> Permit A: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies Kith\Caluuts <br /> sally Baker <br /> 123 Cottage Fox l Lane <br /> Atmvhere.CA()ON X.\ <br /> Ingredients: Enriched flour(\\Leat Flom,macro.reduced iron.tldam»ne. <br /> monouinate.nbotlavin and folic acid).butter(milk.salt).chocolate clips <br /> I shear.clwcolate liquor.cocoa buffer,buret fat(milk). walnuts.sugar,e2es. <br /> salt,artificial vanilla extract.bakum sods. <br /> Contains:Wheat,eggs,milk,soy.walnuts <br /> \el 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 /> Xiea check what type of treatment is used to dispose of waste <br /> ublic Sewer Service E] 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 Facili eck one, x V` l�(y <br /> 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 vath 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 provid roof <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.aovlprograms/PaueslfdbCottaeeFood.aspx <br /> 4 of <br /> EHD 16-276/29/17 CFO REG/PERMITfING FORM <br />