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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />NL%DE IN A HOME KITCHEN <br />Permit M: 12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere. CA 90.=-1 <br />Ingredients: Enriched flow (Wheat flow, niacin, reduced iron. thiamine. <br />nmooujuaie. riboflavin and folic acid), hater (milk, still. chocolate chips <br />(sugar, chocolate liquor, cocoa butter, butterfat (milk), walnuts. sugar, eggs. <br />salt, mlifrcial vanilla extract, baking sada. <br />Contains: Wheat, eggs, milk, soy, walnuts <br />Net Wt.3 oz (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 />(P�le�ase check what type of treatment is used to dispose of waste <br />'IkPublic 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 />dame of Public Water System or Community Services District:f ( U] o4 cS C Gamk�Ljv—\ <br />I 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 y <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.gov/programs/PaaesmdbCottageFood.aspx <br />4 of <br />EHO 1&276/29/17 CFO REG/PERMITTING FORM <br />