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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />NUDE IN A HOME ICITCHE\ <br />Perth M: 12345 <br />Issued In county: Count• nate <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food [ane <br />A ywherc CA 9013_—K <br />Ingredients: Enriched flour (W9reat flour. uiaciu, reduced iron, thiamine. <br />mononitrate. riboflavin and folic acid), butter (talk. salt). chocolate clues <br />(sugar. chocolate liquor. cocoa butter. buuei far (milk), walnuts, sugar. eggs. <br />salt. artificial vanilla extract, baking soda. <br />Contains: \\heat, eggs, milk, soy, walnuts <br />Net Wt.3 oz. (85.049g) <br />Note: Forthe "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 />10 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 on box) [ <br />N Name of Public Water System or Community Services District: M rn i � �iLf V► �Q s <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 water supply— check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: W� <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 moreinformation see CDPH website www.cdph.ca.aov/programs/PaqesifdbCottageFood.aspx <br />4 of <br />