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SAN,JOAOUIN <br /> <br />Environmental Health Department <br />Example: <br />MADE IN A IIONIE KITCHEN <br />Point' 12345 <br />loam' In county: County name <br />Clint:ohne I. Inti C ttokiet. 1% till Walnut: <br />Sally liaket <br />12? C.:outage Food L11110 <br />AllyWheft. CA 90XXX <br />Int!cetlienik: EtnichetlIlmit (Wheat Omit iHtCiui. iruliirrul min. thiamine <br />itionituittate. nbollavin and lithe uicidl. hinter (milk. tall). chocolate dup. <br />(uugau.ChOCOIAleuicer coceuu I,uuiici. billielf,11 wall:Ins %num. cm.. <br />mittietal vanilla extract. baking %oda <br />ContnItitt: ‘1 heat. tutc. milk, toy„1,alnut.. <br />Net 1,1 I. 3 oi. (S5.0490 <br />Note. For the "Issued in County" - Identify the jurisdiction (city/county) where you are obtaining approval <br />Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />*Public Sewer Service 0 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 />Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />0 Name of Public Water System or Community Services District: Moiswel v\wce csv ‘t1 fop <br />El 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 />0 Bacteriological Test (quarterly'): <br />0 Nitrate Test (yearly*): <br />El 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 />Food Processor Course: Initial if you agree to abide by the following: '\1•A <br />Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br />or completion of the California Food Handler course in lieu of the California Department of Public Health <br />(CDPH) food processor course. <br />For more information see CDPH website www.cdph.ca.00v/programs/PagesitdbCottageFood.aspx <br />r r.111.A