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Example: <br />ALADE IN a HOME K rrCHEN <br />Permit #: 12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With waluuts <br />Sally Baker <br />123 Cottage Food Lane <br />Animhere. C.A. 90.1a—K <br />Ingredients: Enriched flour (Wbeat flour, uiaciu reduced iron. thiamine. <br />moeouitrate. riboflavin and folic acid), butter (tralk, salt), chocolate clips <br />(sugar. chocolate liquor. cocoa butter, butterfat (milk). walnuts. sugar, eggs. <br />salt. artificial vanilla extract. baking soda. <br />Contains: Uleat, eggs, milk, soy, walnuts <br />Net \Vt. 3 oz. (85.049g) <br />Note: For the "Issued in County"- identify the jurisdiction (city/county) when: 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 <br />Department immediately. <br />7. Water Source: <br />Pease Identity the water source to be used in Cottage Food Facility (check one box) <br />Name of Public Water System or Community Services District: )w ff t~egi k , PAo t�tpu" IFai CSS <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 tome with a private water supply — check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following:Ilk <br />( <br />Within 3 months of being approved to operate by the Environmental Health Department, please <br />provide proof of completion of the California Food Handler course in lieu of the California Department <br />of Public Health (CDPH) food processor course. <br />For more information see CDPH website www.cdr)h.ca.gov/programs/PagestfdbCottaneFood.asi) <br />EHD 16-27 6127122 4 CFO REG/PERMITTING FORM <br />