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SAN JOAQUIN <br />COI_NTV <br />Environmental Health Department <br />Example: <br />\LADE IN A HOME KITCHEN <br />Permit N: 12345 <br />Issued In county: County name <br />CLocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 C'onase Food Lane <br />Armvhere. CA 90t\.\ <br />Ingredients: Fauiched flora' (Wheat [lour. niacin. reduced iron, tluanune. <br />mononitrate. ribotlariu and folic acid). butter (urilk. salt). chocolate chips <br />(sugar. chocolate liquor. cocoa butter. butterfat (nrihk), wahmus. sugar. eggs. <br />salt. artificial vanilla extract. bakins soda. <br />Contains: INLeat, eggs, mink, soy. walnuts <br />Net IN 1. 3 oz. (85.049g) <br />Note: For the 'Issued in County - Identity the jurisdiction (city/county) where you are obtaining approval. <br />6. Disposal of Waste: <br />Pier 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 />�Pe%a�a Identify the water source to be used in Cottage Food Facility (check one box) <br />I �{ Name of Public Water System or Community Services District: CI D� �YIGCt/ <br />❑ 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.cdoh.ca,aovioroorams(PaaeslfdbCotteaeF-oO asax <br />4 of <br />EHD 16-27 6129117 CFO REG/PERMITTING FORM <br />