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S A N J0A Q U I N Environmental Health Deportment <br /> —COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> remit N: 12.145 <br /> hived In county! Count nem, <br /> Chocolate Chip Cadute ll'ith Walnut, <br /> sully tinker <br /> 123 Canape Foal Lane <br /> Aimsdnrc.CA 90%.1' <br /> tasrxdlenh: Emichod tlae(Rlmnt flow,Id4Vm.mhKnl Iron,dummine, <br /> nlmlcetiaste,riboflavin end folic acid),batter(null salt),chocolate dupe <br /> (wgnr,chocolaw liquor.cocoa Itu"a,Inmetfat(milk), uahnns,su9np elf> <br /> sah,mtificial nwulla extract,baking sudn. <br /> Conular,\\Len,eggs,milk,NY,minah <br /> Net ICL J oz(0.5.6199) <br /> Note:For are Issued in County'-Idenely thejunsdictim(cirylwuntyl where you ere obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> 0 Public Sewer Service ❑Private Septic System <br /> In the event of septic system Failure a plumbing problem,you am required to notify San Joaquin County Environmental Health Departmem <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: Sp,o -Tv t <br /> E]Private Water Supply',Identity the source(well,spring,surface,etc.): <br /> Private Wafer Supply:Initial Waren 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 We of test <br /> (Testing frequency for transient Non-Canmunity 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 rlead is prepared from a home with a private water supply—check with local jurisdialon. <br /> 8. Food Processor Course: Initial if you agree to abide by the following:�-L <br /> Within 3 months of being approved to operate by the Environmental Health Department,please provide proof <br /> of completion of the Califomia Food Handler course in lieu of the California Department of Public Health <br /> (CDPH)food processor course. <br /> For more Information see COPH website www cdph maovlor mms/PagestfdbC Hat Food aspx <br /> 4 of <br /> EHO 1627629/17 CFO REGI ERMFFRRG FORM <br /> Scanned with CamScanner <br />