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SA N,PJ O A Q U I N Environmental Health Department <br /> --COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN' <br /> Perndt it: 12345 <br /> Issued In county: County nnmc <br /> Chocolate Chip cankics XYIhb wV buns <br /> Sally tlnket <br /> 121 Counge Fund lAm <br /> Any%dune.CA 90*M <br /> Ingredients: Eniclted amu(Wbcm Ilm..nucha,mcmced ima.ddamine, <br /> ntmtntitmte,ritrollacin and folic acid).bona(milk.Solt),chocolate dols <br /> ('near,clmcolate liqum,cocoa bunter Innterfnt(milk), mi n ls,sugm,eggs. <br /> salt,artificial vnnilln cWna,b along sola. <br /> Cmdolns:Wheat,eggs,null"soy,w.inats <br /> Nei A'1.3.74115.0499) <br /> of :For the'Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. DISPoSaI 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 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.): <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 Ceffied Laboratory. Either attach lab results or provide name of lab,date& <br /> results in space provided next to type of lest." <br /> '(Testing frequency for transient Non-Community Water Systems after initial testing) <br /> /,Bacteriological Test(quarterly*): P � fxl <br /> lit-f,l f l �a <br /> FUNitrate Test(yearly'): l <br /> Nitrite Test(every 3 years'): <br /> "Additional information may be required It 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,pie dovide proof <br /> of completion of the California Food Handler course in lieu of the California Department of Public ealth <br /> (CDPH)food processor course. <br /> For more information see CDPH website www.cdph.co.aovlprootamstPagestfdbCottaneFood.aspx <br /> 4 of <br /> EHD 16-276129117 CFO REGIPERMITTING FORM <br />