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SANAAOUIN <br /> <br />Environmental Health Department <br />—COUNTY--- <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit 4: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere, CA 903C1CX <br />Ingredients: Enriched flour (Wheat flour, niacin, reduced iron, thiamine. <br />mononitrate. riboflavin and folic acid), butter (milk, salt), chocolate chips <br />(sugar. chocolate liquor. cocoa butter. butterfat (uilk), walnuts. sugar, eggs. <br />salt, artificial vanilla extract, baking soda. <br />Contains: Wheat, eggs, milk, soy, walnuts <br />Net Wt. 3 oz. (85.049g) <br />Note: For the issued in County' - Identify the jurisdiction (city/county) where you are obtaining approver <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />Public Sewer Service 0 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 />ikillame of Public Water System or Community Services District: 4-14 bi— LA U1/4 17(i426S4- <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 />ID Bacteriological Test (quarterly*): <br />Nitrate Test (yearly: <br />0 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: _Ra t <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 wvAv.cdph.camovtprograms/PagesfidbCottaqeFood.asoa <br />4 of E <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM