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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />\LODE In A HOME KITCHEN' <br />Permit 0: 11345 <br />Issued In county: County name <br />Chocolate Clup Cookies with walnuts <br />Sallyaaker <br />123 Cottage Food Lane <br />.Amvhere. CA 901.0 <br />Ingredlents: Emiched flora (Mlear flow. niacin, reduced icon. tluuswse. <br />mononitmte. riboflnsm and folic acrd), boner (hulk. salt), chocolare claps <br />(sugar. chocolate liquor. cocoa bunct. bmrertnt (milk). scnlnms. sugar, eggs. <br />salt, anificial vanilla cxlrnct, baking soda. <br />Contains: Wheal. eggs, milk, soy, walnuts <br />.Net %Vt 3 oz (85.049g) <br />Note! For the 'Issued In Counly'- Identfy the Iudsdictlon (cityloounty) where you are obtaining approval. <br />6. Disposal of Waste - <br />Please check what type of treatment is used to dispose of waste <br />Ip7 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 />j Name of Public Water System or Community Services District: c0l� 6 1A FN <br />❑ Private Water Supply—, Identify the source (well, spring, surface, etc.): J I <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 y <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: I L <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 in(onnatlpn sae CDPH website www.cdoh.ca.aovlorograms/PaoeslfdbCottaseFood.asox <br />4 of 5 <br />