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SA NUJ OAQ U I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HUME KITCHEN <br /> Peumttt 4: 12345 <br /> Issued in county: Counly name <br /> Chocolate Chip Cookies Willi Walnuts <br /> Sally Baker <br /> 123 Connge Food Lane <br /> Anysvhete.CA 90.1"\.-X <br /> Ingredients: Enriched flmv(V9reat flay,niacin,reduced iron,thiamine. <br /> monouitrnte,riboflavin and folic acid).butter(nsilk.salt).chocolate chips <br /> (s agar,chocolate liquor,cocoa butter,banafint(milk), umlauts.sugar,eggs. <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:-Wheat,eggs,mllk,soy,.valnuts <br /> Net Wt.3 oa(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 /> 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: aoY\( 6V_tz�"j <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 vdth 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 webshe www.cdoh.muovlgroammslPagesifdbCottageFood.asox <br /> 4 of <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />