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SANJOAQUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />\LADE INA HOME KITCHEN <br />Permit tt: 12345 <br />Issued in comfy: County name <br />Chocolate Chip Coolies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Ain Mere, CA 90.1 <br />Ingredients: Enriched flour ('Vicat flour. tllacia reduced iron. thianvne. <br />monomitmte, ribollaxio and folic acid), buffer (mill:. salt), chocolate chips <br />(sugar, chocolate liquor, cocoa butter. butterfat (milk"). walnut. shear. eees. <br />salt, artificial yanifia extract, bakine soda. <br />Contains: wheat, eggs, m11k, soy, walnuts <br />Set Wt. 3 oz. (g5.049g) <br />Note: For the "Issued in County- Identify the jurisdiction (city/county) where you are obtaining approval. <br />6. Disposal of Waste: <br />Plea e check what type of treatment is used to dispose of waste <br />�Vj 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 box) <br />Ed <br />Name of Public Water System or Community Services District: rn\O /3Cn )OC1_0 <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 hone with a private water supply — check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: (--%J <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.edph.eaaovlpronr s/PaaesfldbCottansFood.aspx <br />4 of <br />EMD 16-27 6/29117 CFO REG/PERMITTING FORM <br />