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SAN JOAQUIN <br />—COUNTY <br />Environmental Health Department' <br />Example: <br />MADE IN A HOME KITCHEN <br />Per olt p: 12745 <br />Issued In county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food lam <br />Any%vhere. CA K0LX <br />Ingredients: Enriched flour (Wheat floor, niacin. reduced iron thiamine, <br />mononitrate, riboflavin and folic acid). butter (milk, salt), chocolate chips <br />(sugar, chocolate liquor. cocoa butter, butterfat (null). walnuts, sugar. eggs, <br />salt, artificial vanilla extract, baling soda. <br />Contains: Wheat, eggs, milk soy, walnuts <br />Yet Wt. 3 oz (95.649g) <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 />® Name of Public Water System or Community Services District: ,John Jones Water Treatment <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 home with a private venter supply — check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: KD <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.cdoh.ca.aovli)rosirams/Pages/fdbCottageFood.aspx <br />4of5 <br />EHD 16-27 6129117 CFO REGIPERMITTING FORM <br />