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SAN.d QUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HONME IQTCHEN <br />Permit #: 12345 <br />Issued In county: County name <br />Chocolate Clip Cookies With walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere. CA 90\%N <br />Ingredients: Enriched Bou (Wgteat Bou, ninchL reduced iron. diamine. <br />mononitrate. riboflavin nod folic acid). butter (milk, salt). chocolate clips <br />(sugar. chocolate liquor. cocoa bmta. butterfat (null:), aroWuts, sugar, eggs. <br />salt, artificial smnilla extract, baking soda. <br />Contains: %%heat. eggs, milk soy, walnuts <br />Net Wt. 3 o7- (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: <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 (quartedy'): <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: <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 website www.cdph.ca.govlorogmmstPages/fdbCottageFood.aspx <br />4of5 <br />EHD 16-27 6/29/17 CFO REGIPERMITTING FORM <br />