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SAN JOAQUIN <br />Environmental Health Department <br />Example: <br />]LAME IN A HOME KITCHEN' <br />Permit #: 1234.5 <br />Issued in county: County name <br />Chocolate Chip Cookies With R'ahnns <br />Sally Baker <br />173 Cottage Food Lane <br />Any%vhere. CA 90SS.0 <br />Ingredients: Ewiclted flow ( Wheat flow. tnacht, reduced iron thiaunue. <br />mononitrate. tibotlaeiu and folic acid). butter uuilk. saft). chocolate chips <br />(sugar. chocolate liquor. cocoa butter. burerfal (milk). wuluuts. sugar. eggs. <br />salt. artificial vanilla extract. hakiu: soda. <br />Contains: 11 heat. eggs, milk soy, m alnuts <br />Net til. 3 oz. (85.0498) <br />Note: For the "Issued in County"- Identify the jurisdiction (city/county) where you are obtaining approval. <br />S. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />dPublic 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 />dName of Public Water System or Community Services District: PG & E /CAI woo <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 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: RD <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.edoh.ca.oov/procirams/Paaes/fdbCottageFood.asax <br />4 of <br />EHD 10.27 0/28/17 CFO REG/PERMrrTING FORM <br />