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SAN JOAQUIN <br />Environmental Health Department <br />Example: <br />MADE IN A HOME ICITCHEN <br />Permit M 12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With Wahmts <br />Selly Baker <br />123 Cottage Food Lane <br />Anywhere. CA 90X—XX <br />Ingredients: Enriched flour (Wheat flour. uiaciu. reduced iron. thionune, <br />mononitrate, riboflavin and folic acid). butter (hulk, salt). chocolate chips <br />(sugar. chocolate liquor, cocoa butter, butterfat (hulk). wahntts, sugar. eggs. <br />salt, artificial vanilla extract, baling soda. <br />Contains: Wheat, eggs, intik, soy, walnuts <br />NetWt. 3 oz. (85.049g) <br />Note: For the "Issued in County" - Identify the jurisdiction (city/county) where you are obtaining approval. <br />6. DisRpsal of Waste: <br />Pie se 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 am required to notify San Joaquin County Environmental Health Department <br />immediately. <br />7. Water Source: <br />Pg�e Identify the water source to be used in Cottage Food Facility (check qne tine) <br />C1J Name of Public Water System or Community Services District: <br />❑ Private Water-8upply 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 />"Adds ional 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 prove oof <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.edph.m.gov/programs]Pages/ldbCottageFood.asp <br />4 of <br />EHD 16-276129117 CFO REGRERMITTIN4FORM <br />