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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />MADE IN A HON11E KITCHEN <br />Permit p: 12345 <br />Issued In county: County name <br />Chocolate Chip Coolies With Walnuts <br />Sally Baler <br />123 Cottage Food )ane <br />Anywhere. CA 9030CX <br />Ingredients: Enriched flow (Wheat flour, niacin. reduced iron. thiamine. <br />mononitrate, riboflavin and £otic acid), butte (mill:- sally, chocolate daps <br />(sugar, chocolate liquor. cocoa butter. bmnerfat (milk), wahnns, sugar, eggs. <br />suit, artificial vanilla extract. baking soda. <br />Contains: Wheat, eggs, milk, soy, walnuts <br />Net Wt. 3 oz (85.049g) <br />Note. For the "Issued in County- Identify the jurisdiction (citylcounty) where you are obtaining approval. <br />6. Disposal of Waste: <br />Pleasp 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 l box) <br />[,Name of Public Water System or Community Services District: �+�1 of T1 -o( Com; 0,4- <br />El <br />.4=1.❑ 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 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, pleaser ide proof <br />of completion of the California Food Handler course in lieu of the Caflfomia Department of Public ealth <br />(CDPH) food processor course. <br />For more information see CDPH website www.cdoh.ca.uovhrroaremslPaaeslfdbCottaaeFood.asnx <br />4 of <br />EHD 16-27 6/28/17 CFO REG/PERMITTING FORM <br />