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SAN JOAQUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME IQTCHE\ <br />Permit 8: 12345 <br />Issued In tnunh': Counh'lnme <br />Chorolale CI1ip Cookies With Walmns <br />sally Baker <br />123 Cottage Food Lurie <br />As1)nvh<re, CA 90..NXX <br />Ingredients: &niched flour (ltgteat flour, niacin, reduced iron. thinuune. <br />monouitmte. ribofimin and Colic ncid), boner (milk, sal), chocolate chips <br />(sugar. chocolate liquor, cocoa biter, butterfat (milk). aalnnts, sugar. eggs. <br />salt artificial vanilla extract, hiking sods. <br />Contains: Wheal, eggs, milk, soy, walnuts <br />,Net wt.3 oz (85.0199) <br />No eE For the 'Issued in County'- Identify the junsdicbon (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 />Name of Public Water System or Community Services District: City of Tracy <br />❑ Private Water Supply", Identify the source (well, spring, surface, <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 />•(Tesfing 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 Informa0on maybe required If food is prepared from a home with a private water supply—check with IomijurisdiClon. <br />MHJ <br />B. 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 Califomia Department of Public Health <br />(CDPH) food processor course. <br />For more information see CDPH websim www Wnh ca nov/orogmms/Panes/fdbCottaneFood asox <br />4 of <br />EHD 1&270/29/17 CFO REGIPERMnTING FORM <br />