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SAN'l000UIN <br />COIJNTY <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit N: I2345 <br />Issued In county: County name <br />Chocolate Chip Cookies Wilts Weluuts <br />Salts• Baker <br />IV Collage Food Lane <br />An)whem. CA 90XXX <br />Ingredients: Ennched halt (Wheat Ootu, nincm, reduced icon, thiamin. <br />mcnanitmte. iibollasin and folic acid). butter (tuilk, salt), chocolate chips <br />(mgat, chocolate liquor, cocoa butter, butterfat (nulk). wahmts. stivar. eggs. <br />salt. artificial iwulla extract, baking soda. <br />Contain: \\'beat, eggs, milk, soy, walnuts <br />Net Wt. 3 oa- (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 />kO�Fubhc 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: L46o; I y � CL+cI - <br />am <br />❑ Private Water Supply, Identify the source (well, spring, surface, etc.): t <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 Slate 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: A_ `1 <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 iaWw,cduh.oa.aovlproaram_TaaeslfdbCott•aeFood asex <br />4 of <br />