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SAN10 A Q U I N Environmental Health Department <br /> -- COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit k: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90)LXX <br /> Ingredients: Enriched flour(N9neat flour,niacin,reduced iron.tkianune. <br /> incriminate,riboflavin and folic acid),butter(milk.salt).chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk), walmus.sugar.e22s. <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3 ox.(85.049g) <br /> No e: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 /> r 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 on box) <br /> Name of Public Water System or Community Services District: — 1 <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 with local jurisdiction, <br /> 8. Food Processor Course: Initial if you agree to abide by the following: —If) <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 /> Formore information see CDPH website www.cdoh.ca.oovlorogramsiPages/fdbCottaneFood.aspx <br /> 4 of <br /> EHD 16-276/29117 CFO REG/PERMITTING FORM <br />