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SAN JOAQUIN <br />Environmental Health Department <br />Example: <br />NL%DE IN A HOME KITCHEN <br />Permit p: 12115 <br />Issual in county: County name <br />Chocolate Ctup Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Law <br />.3rnivI ere. CA 90.=X <br />ingredients: Emiched flour (Wlxai Boar. niacin, reduced iron, thiamine, <br />mononitrate, riboflavin and folic acid). butter (milk, salt), chocolate clips <br />I sugar. chocolate liquor. cocoa butter. butterfat (milk). walnuts, Susan. eggs. <br />salt. artificial vanilla exuact. baking s ta, <br />Contains: Wheat, eggs, mill:, say, walnuts <br />Net Wt. 3 oz (85.079g) <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 <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: <br />ZPrivate Water Supply", Identify the source (well, spring, surface, etc.): W <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 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 p vide 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.gov/programs/Pages/fdbCottageFood.aspx <br />EHO 1 6-2 7 6129117 CFO REG/PERMTTING FORM <br />