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SAN. JOAQUIN <br />COUNTY— <br />Example: <br />OUNTY <br />Environmental Health Department <br />Example: <br />NUDE IN A HO\IE KITCHEN <br />Permit q: 12345 <br />Issued in count': Counts name <br />Chocolate Chip Cookies With 11 Monts <br />Salk Baker <br />123 Cottase Food Lane <br />An%yvhere. CA 90VCN <br />Ingrerllents: Enriched floor ( Wheat flour. niacin. reduced iron. thiamine. <br />mononitrate. riboflavin and folic xtd). biter (milk. saio. chocolate chips <br />swear. chocolate liquor. cocoa buttes butterfat Imilk). walnuts. sugar, coos. <br />salt. artificial vanilla esnu <br />act. bakis soda. _ ` <br />Contain%: R heat, eggs, mill:, soy. walnuts <br />Net 1\ t. 3 oz. (8,.049-) <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 am 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 8 <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: &>4_ <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 websde www.cdph.w.gmiprogramsfPageslfdbCottageFood.aspx <br />4 o 5 <br />EHD 16-276/29117 CFO REG/PERMfTTING FORM <br />