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SA6.10AQUIN <br />-COUNTY- <br />Example: <br />COUNiY- <br />Environmental Health Depaitment <br />Example: <br />ADE IN A HOME KITCHEN <br />Permitg: 13315 <br />Issued in count•: Counh• name <br />me Chip Cnoui WWI Walmas <br />Salic Bata' <br />133 Crnt;w rod [core <br />Amldr.r. CA 90ss.X <br />Ingmiknn: Emiclich flan (ss"heat 0aq, runchL mtuced imo, thi mine. <br />mencmirmre, nboflatiu mtd folic.widi. Mann(atilt. M11). d~bte cid)n <br />(v�ea1. clacrntnre 1�, axYni iuma. brow fat imilkl, aalnms. stagy. cam. <br />salt. nrtihcinl samlln plfact. Inhine srda <br />Coptalnc L\bnt.. mllh cop. matnuts <br />\N Wt.3 oz (8.5.049;) <br />Note: For the 7ssued in County- Identily the jurisdiction (cf ylcounty) where you ale 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 am required to rwufy 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 CGI V,0+15t' SefV1C21 <br />❑ Private Water Supply", Identify the source (well, spring, surface, etc.): <br />Private Water Supply. Initial Water Quality Results <br />Check foxes below if initial water testing has been completed. <br />All testing must be done at a State Certified Laboratory. Either attach lab insults or provide name of lab, date & <br />results in space provided next to type of test <br />'(Testing frequency for transient Non-Cominunity Water Systems after initial testing) <br />❑ Bacteriological Test (quarterly'): <br />❑ Nitrate Test (yearly`): <br />❑ Nitrite Test (every 3 years'): <br />'-Additioml information may be required it food is prepared from a lone with a private water supply- check ttith local jursdidion. <br />8. Food Processor Course: Initial if you agree to abide by the following: 19 M <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 COPH website www oduh ca.o lorooramslPaoesftbCottageFood,aspx <br />tof $ - _. __ ____ ____. _ _ _ . _. .. ..____.._.__.. <br />EHD 1627 6129117 CFO REWERMITHNG FORM <br />