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SANAOAQUIN <br /> <br />Environmental Health Department • <br />—COUNTY— <br />Example: <br />\ MADE IN A HOME KITCHEN <br />Permit 13: 12345 <br />Issued in county: County name <br />Chocolate Chip Coolies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere. CA 9031XX <br /> <br />Ingredients: Enriched flour (Wheat flout niacin, minced iron. thiamine. <br />mononitrate. riboflavin and folic acid). butter (milk, salt), chocolate chips <br />(sugar. chocolate liquor, cocoa butter. butterfat (milk), walnuts. sugar. eggs. <br />salt. artificial vanilla extract. baiting soda. <br />Contains: Wheat, eggs. milk, soy. walnuts <br />Net WI. 3 oz. (85.049g) <br />Note: For the Issued in County - Identify the jurisdiction (city/county) where you we obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />II) Public Sewer Service 0 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: Pgase Identify the water source to be used in Cottage Food Facility (check one box) <br />Name of Public Water System or Community Services District: phei vumb tooder dio...4_rict <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 />0 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: LCIS <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 websfte VAVW.cd h .ca . a °yip r oa r a m sfP a gest(' dtrCottaaeFood asox <br />4 of 5 <br />EHD 16-27 6/29/17 CFO REG/PERMM1NG FORM