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Ir <br />�>a>) r t <br />►II ►► F9 + Flo ill <br />Oo0 <br />o — <br />n <br />" SAN JOAQUIN <br />Environmental Health Department <br />Example: <br />NNL4DE IN A HONIE KITCHEN <br />PewitM ILV45 <br />Issued In eouah': C000ly Meme <br />Chocolate Nip Cookie' with Walnuts <br />Sally Bider <br />1'_3 Cmmge Food Lauc <br />AnyN%1 e. CA 9011 <br />Ingredients: Euncbed amv (%IWAI Flour. ui,,i L reduced iron. duariam, <br />mononinate. ribofavin and folic acid). boner (rain sell), cbocobste duPs <br />(sugar. choculam liquor, cocoa butter, bmnfat (milk)• xvbmts. sugar, eggs. <br />salt arrificial tanitk cctmct baking oak. <br />Courtiers: wheat, eggs, milk, sop, ardnms <br />Net Rt. J oz (85.049g) <br />of : For f -issued in County- Identify Nrejunsdktion tcdyk-nfy) where you are obtaining approval. <br />6. DISOOSaI 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 or plumbing problem, you are required to notify San Joaquin County EnvlrenmeMeI Heakh Deparbnent <br />immediately. <br />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 (' t i1Jt Q ML�-h <br />❑ Private Water Supply", Identify the source (well, spring, surface, `etch.): �J <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 8 <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 />"Add ficnal Information may be required if food IS Prepared mxn a home with a private water supply - check with lutea )udsdiceon. <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 weesde www odph a ao iproa msnPnaes/fdbCotuaeFood.espx <br />lo!5 <br />EHD 16-27 612W17CFO REGIPERMITTING FORM <br />etc <br />) <br />\ ter <br />turn <br />haft <br />