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SAN JOAQUIN <br />---COUNTY— <br />Environmental Health Department <br />Example: <br />\LADE IN A HOME KITCHEN <br />Permit p: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies With Walnuts <br />Saliv Baker <br />1'_3 Corsage Food Lane <br />Amiyhere. Cel 90. x"\ <br />Ingredlents: Enriched flour (R9tnt flour. niacm. reduced iron, thinnwx. <br />mononitrate, ribofimin and folic acid). butter (bulk, salt). chocolate clips <br />(suear, chocolate liquor. cocoa butter, butterfat (rtilk). ummuts, suer, eggs. <br />salt. artificial %nnilla extract, baking soda. <br />Contains: Wheat, eggs, milk soy, walnuts <br />Feu q't. 3 oz (gi049g) <br />ate: For the "Issued in County'- Identify the jurisdiction (cVcounty) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />El Public Sewer Service <br />❑ 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 />immedalely. <br />7. Water Source: <br />Pease Identity the water source to be used in Cottage Food Facility (check one box) <br />❑x Name of Public Water System or Community Services District: West Side Irrigation District <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.cdph.r gm/prooramslPaaeslfdbCottaaeFoodasox <br />4 of <br />EHD 16-27 6129117 CFO REG(PERMfrTING FORM <br />