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, S fN JO h Q I N <br /> Environmental Health Department <br /> COUNTY-- Example: <br /> MADE INA HOME KITCHEN <br /> Permit X: 12345 <br /> Issued in counts: Countv name <br /> Chocolate Chip Cookies With R aluuts <br /> Sally Baker <br /> 123 Cottage Focal Lane <br /> Alnwhere.CA 90'M <br /> Ingredients: Enriched 110111(tt'heat hour.niacin.reduced iron.tluaumle. <br /> mononitrate.riboflavin nud folic acid).bullet onilk.salt).Chocolate daps <br /> (sugar.chocolate liquor.cocoa butter.butteriat(milk). wit a s.sugar.e!_es. <br /> sah.artificial vanilla extract.baking soda. <br /> Contains:IN-heat.eggs,milk.soy.walnuts <br /> Net 111.3 oz.(85.049-1) <br /> Note:For the"Issued in County"-Identify the jurisdic ion(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 /> JK 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 /> X Name of Public Water System or Community Services District: 't"c-�CX ir' e c, <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: <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 www.edgh.t:a.gov/procirams/PaaosifdbCottageFood.asux <br /> 4 of 5 <br />