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SAN JOAOUIN <br />CU . <br />Environmental Health Department <br />Example: <br />MADE In A HOME KITCHEN <br />Permit n: 1235 <br />Issued In county: County name <br />Chocolate Chip Cookies With Walnuts <br />Mly Baker <br />123 Cottage Food Lane <br />An)nvhere. CA 90MCX <br />Ingredients: Enriched flour (Micat flour, huaciLL reduced iron. thimu ue. <br />mououitmte. riboflavin and folic acid). burner (tiik. salt), chocolate clips <br />(sugar, chocolate liquor, wean butter. butterfat (milk). walnuts, super, eggs, <br />sah. artificial vanilla extract. baking so(kn. <br />Contains: \{Leat. 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 approval. <br />6. Disposal of Waste: <br />P7'F <br />ea a check what type of treatment is used to dispose of waste <br />lFPublic Sewer Service Private Septic System <br />In the event of septic system failure or plumbing problem, you are required to notify San Joaquin County Environmental Health <br />Department immediately. <br />7. Water Source: <br />Pease Identify the water source to be used in Cottage Food Factfty (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, 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 />'-Addifional Information may be required if food Is prepared from a Mme 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 (CDPH) <br />food processor course. <br />For mom information see CDPH website wW W.cdnh "a ggylg mms/aagedfdhCotLpeFood.asoa <br />F7fii <br />