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SA NJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE EN A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With Walnut, <br /> Sall•Baker <br /> 123 Cottage Food Lane <br /> Umvhere.CA 90XXX <br /> Ingredients: Enriched flour(Wheat flour.niacur.reduced iron,thiamine. <br /> mononitrate.riboflavin and folic acid).butter(hulk,salt).chocolate chips <br /> (sugar,chocolate liquor.cocoa butter.butterfat(milk). walnuts.sugar,eggs, <br /> salt,artificial vanilla extract.baking soda. <br /> Contains:NVheat.eggs,milk,soy.walnuts <br /> Net N I.3 oz.(85.0498) <br /> Note:For the 'Issued in County"-Identify the jurisdiction(city/cowrtyi where 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 ❑ 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) 5, Cy CA <br /> Name of Public Water System or Community Services District: � 23 <br /> C t.�U l';( <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 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: A A G <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.odah.ca.uov/procirams/Paaes/fdbCottaueFood.asax <br /> ^ af5 <br />