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SAN ',J O A Q U I N Environmental Health Department <br /> coup_Y <br /> Example: <br /> 3LaDE INA HOME KITCHEN" <br /> Permit N: 12345 <br /> Issued in counm: Counts name <br /> Chocolate Clup Cookies With A'alu tts <br /> sally Baker <br /> 123 Cottage Food Lane <br /> -bil shere.CA 9 VCX <br /> Ingredients: Enriched flour(Agreat flour.niacin.reduced iron.thiamine. <br /> mononitrate.riboflavin and folic acid).butter(nulk.salt).chocolate claps <br /> (suear,chocolate liquor,cocoa butter.butterfat(ruilk). walnuts.sugar.eggs. <br /> salt,artificial xw,Ila extract.baking soda. <br /> Contains:Wheat.eggs,mUL sop.walnuts <br /> Net RY.3 oz.(85.049g) <br /> Note:For the"Issued in County"-Identify the junstifton(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 a 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: Ripon, CA <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 hwne with a private water supply—check with local jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: KLO <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.cdoh.ca.aovloroaramslPaaesffdbCoffiaeFood.asox <br /> 4 of <br /> EHD 16276129117 CFO REG)PERMITTING FORM <br />