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SAN JOAUUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />MADE 11N A HOME 1UTCHUN <br />Permit#: 12345 <br />Issued to county: County name <br />CLocotme Chip Cookies l@idr Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />.auywhere. CA 90,\%V <br />Ingredients: Eanched floor (%k beat flour. oiaciu, reduced icon, aneurine. <br />mononimic. riboflavin and folic acid). better (oink, salt). chocolate daps <br />(cozy. cluocolate liquor. cocoa butter. butterfat (otitk), walnuts. sugar. eggs. <br />sats. w tificial vmulla extract. baking soda. <br />Contains: Wheat, eggs, mak soy, oralouls <br />Net WL 3 oz. (85.0498) <br />Note: For the "Issued in County"- Identify the jurisdiction (cibdtounfy) where you are obtaining approval. <br />6. Disposal of Waste: <br />Fleasp 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 feature or plumbing problem, you are required to notify San Joaquin County Environmental Health Department <br />immediately. <br />7. Water Source: <br />Zdenti(y the water source to be used in Cottage Food Facility (check one box) <br />me of Public Water System or Community Services District: a t i -6(t is W tit P- SeVIltCCS <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 hone with a private water supply —check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: M I <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.cdph.ca.aovioroomms/Pages/fdbCottageFood.asp <br />4 of 5 <br />