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SAN IOAQUIN <br />COUNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit #: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere. CA 903N <br />Ingredients: Enriched flan (Wheat flour, niacin, reduced iron. thiantine. <br />momminmte, riboflavin mid folic acid), butter (milk:. salt), chocolate chips <br />(sugar, chocolate liquor. cocoa butter, butterfat (milk). walnuts, sugar, egg_,. <br />salt artificial vanilla extract, baking sada. <br />Contains: Wheat, eggs, milk, soy, walnuts <br />Net Wt. 3 oz (65.049g) <br />Note. For the "Issued in County' - Identify the jurisdiction (city/county) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />VPublic 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 Deparhnent <br />immediately. <br />7. Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />X Name of Public Water System or Community Services District: Trq ey W QAec DePCA C+ ttMet%' <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 Stale 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: _LIL"'t- <br />Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br />of completion of the Cal'Ifomia 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.ra.aovloroarams/Pacies/fdbCottageFoodasox <br />4 of <br />EHD 16-276129117 CFO REG/PERMITTING FORM <br />