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SANJ O A Q U I N Environmental Health Department <br /> COUNTY___ <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit d: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cooldes Nvith Wabmts <br /> Sally Baker <br /> 123 Connee Food Lane <br /> An)where,CA 90)DLN <br /> Ingredients: Enriched Boor(Wheat floor,niacin,reduced irou,thiamine. <br /> monealmue,riboflavin and folic acid).buttet(Hulk.salt),chocolate clips <br /> (sugar,chocolate liquor,cocoa butter,bunei lot(null:), woloo s.sug,v,eggs. <br /> salt,artilicial 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 approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> Public 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 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: �, X-d <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 pdvate water supply—check with local jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following-%A/ <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 more information see CDPH website mnm.cdph.ca.gov/programs/Pa-ges/fdbCottageFood.aspx <br /> 4 of <br />