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SAN10 n Q I I I N Environmental Health Department <br /> COUNTY I1 <br /> Example: <br /> \LADE LN A HOME IQTCHEN <br /> Permit d: 1234., <br /> Issued in county: County name <br /> Chocolate CWP Coolies With Walnuts <br /> Sally Baker <br /> 123 Cottase Food Lane <br /> Auslvhere.CA 90\"t"N <br /> Ingredients: Enriched flour(�Ilteat flour.niacin.reduced iron.thiamine. <br /> mououimte.riboflavin and folic acid),butter(milk.salr).chocolate claps <br /> (snsar.chocolate liquor.cocoa butter.butterfat(milk). uvaWuts.suer.eees. <br /> salt.artificial vanilla extract.baking soda. -- <br /> Contains:Wheat,eggs,milk soy,walnuts <br /> Net Wt.3 oz(8.,.049g) <br /> Note,For the'Issued in County -Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of f waste <br /> F1 Public Sewer Service LJ 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: <br /> ❑ Private Water Supply", Identify the source (well, spring, surface, etc.): NN <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 /> ❑,t Bacteriological Test(quarterly*): <br /> LI <br /> Nitrate Test(yearly*): sP'P G0QGVP <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.r .gov/programs[Pages/fdbCottageFood.aspx <br /> 4 of <br /> EHD 16-276/29/17 CFO REG/PERMMrING FORM <br />