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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />ILADIE kN A ]RO-ME KITt'HEl <br />peva ll #: 12345 <br />llssned hi commits: County name <br />Chocolate Chip Cookies With Walnuts <br />Sully Baker <br />123 Conage Food lie <br />Anywhere. CA 9020-X <br />Itgredk®ls: Enriched Bot¢ (Ulm floor. niacin rethtced iron- thianti¢e. <br />mououitmte. tiberflatin and folic acid). Miner (milk. salt). chocolate chips <br />(sup¢" chocolate lupmr. cocoo Miner. butterfat (mill). %"tutus. mq r. egg, <br />salt, anibcial vanilla extract, baking soda. <br />C eMtain5: Whell, eggs, milk, sox, WnOnals <br />Net 119.3 oz. (R3,0490 <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 />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 />immediately. <br />7. Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />%Narne of Public Water System or Community Services District: ! . A Aa_- <br />❑ Private Water Supply**, Identify the source (well, spring, surface, etc.): it n r <br />Private Water Supply: Initial Water Quality Results 1 <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 localjurisd'xlion. <br />8. Food Processor Course: Initial if you agree to abide by the following: ("a <br />Within 3 months of being approved to operate by the iEnvironmental 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.ca.govlprogmmstPaoestfdbCottaoeFood.asox <br />e M I <br />