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SAN J O A Q U I N Environmental Health Department <br /> COUNTY- <br /> Example: <br /> )LADE IN A HOME ICITCHEN <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Clip(.ootaes With Walnuts <br /> sally Baker <br /> 123 Cottage Food Lane <br /> 6rnyyhere.CA 90=1; <br /> Ingredients: Enriched flour(RLent flour.uincut,reduced icon.thinnwte. <br /> mononitrate.ribollavin and folic acid).butter(hulk.salt).chocolate clups <br /> (sugar.chocolate liquor.cocoa butter.butterfat(milk). %%ohms.sugar.eggs. <br /> salt.artificial s culla extract,baking soda. <br /> Contains:NN heal,eggs,milk say,walnuts <br /> Net 11 t.3 oz(85.0498) <br /> Note:For the'Issued in County°-Identify the Jurisdiction(cify1muntyl 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 /> 1Z Name of Public Water System or Community Services District: C; - <br /> oq Ma(*KC. <br /> ElPrivate 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 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 p.novloroommslPaammdbcottaceFood.asox <br /> 4 of <br /> EMD 16-27 6!29/17 CFO REGIPERMITTING FORM <br />