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Sn N.J O n Q I I ( N Environmental Health Department <br /> —FiCOU FNiITYIJ <br /> Example: <br /> MADE In A HOME KITCHEN <br /> Permlt N: 12315 <br /> Issued In county: County new <br /> Chocolate Clop Cookies R'itb w'alunts <br /> Salk Baker <br /> 123 Cottage Food IAne <br /> Anywhere.CA 90VO: <br /> Ingredients: Enriched flour(W7teat flan.niacut.reduced icon.(lunnunc. <br /> nronouirrate.ribollasin and folic acid).barter(uulk.salt).chocolate cups <br /> (sugar,clrocolaie liquor,cocoa butter.butterfat(rtulk). walnuts,sucar.eggs. <br /> salt.artificial miilla emact.baking saki. <br /> Contains:\Neat,eggs,collie.soy,walnuts <br /> \el R'1.3 oz.(W.049g) <br /> Note:Forthe"Issued in County"-Identify the julisdiction(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: <br /> ® Private Water Supply", Identify the source (well,spring,surface, etc.): Private Well <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 /> "Addttional information may be required if food Is prepared from a home with a private water supply—check with lccaljudsdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: AG <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 webstte www.cdoh.ca.gov/procirams/Paaes/fdbCottageFood.asux <br /> 4 of <br /> EHD 16-27 6/29/17 CFO REGIPERM rrTING FORM <br />