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SAN JOAUUIN <br />Environmental Health Department <br />Example: <br />MADE INA HOME KITCHEN <br />Permit M: 12145 <br />l,sued in counts: Counts name <br />Chocolate Clip Cookies With 1%aluma <br />Sails Riker <br />12? Cottage Food Lane <br />Aassvhere. CA 90.C.N'C <br />Ingredients: Emichcxt Ilum i%% hear flour. widereduced ion. thiamine. <br />jumnsu lmte. ribollann and folic acidl- butter (milk. vA), chocolate drips <br />(mumu. desolate liquor. cucon butter. bunctfat tmilk 1, rsalunts, sugar. egg,. <br />s.-ih, artificial squilla exnact. baking soda <br />Contains: R heat, eggs, milk so). walnuts <br />Set yt1.3 oz. (S1.0499) <br />Note: For the "Issued in County"- Identify the junsdiction (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 <br />❑ 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: Tracy Utilities <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 />❑ Nitrite Test (every 3 years*): <br />'"Additional information may be requred if two 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: MH <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.odph.ca.nov/programs/Paaes/fdbCottageFood.aspx <br />EHD 16-27 6/29117 CFO REG/PERMnTING FORM <br />