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Je• <br />SANAMJUIN <br /> <br />Fnvironmental Health Deparit ,,,, <br />Examp:e; <br />N1.1DE l\ t1ONIE <br /> <br />Pri null I:343 <br />1.suv41 in unt, I .unt% manly <br /> <br />chiNoLitc Le p( With tt Apes <br />sAll Mikes <br />12 1 f (waste nod Lute <br />.%ny« hoc ( A '00XIVN <br />letreilleettt: Ltuultell flout Mica nom iiiactu, acatitccd hop <br />t)vnionittate. iibitatvin and folic anal i boner i tinlk .alt I lnkalatt oups <br />siicat cloacularc luiricv cocoa bunt, limn fat tiialkt %% alines stivai • <br />%lb. artificial (aiiilla ct‘ttact tubiiv .aLla <br />Cootabri: Wheat. mg% milk. ‘o,. nalaut. <br />Net 1%1. 3 oz. <br />Noft For tho 'Issued in County - laentoly tee funsorctron (CV/county) Where you are obtaining approval <br />6. Disposal of Waste: <br />"lease check what type of treatment is used to dispose of Wage) <br />N'public Sewer Service rl Private Septic System <br />In :be event of septic system failure or plumbing Problem. you are required to ntgiN San Joaquin County irunniiitai Health Deuartme n• <br />.-moiatolv <br />; . Water Source: <br />Pease identify Inn water source to be used in Cottage Food Facmtv (check one box) <br />NiName of Public Water System or Community Services District si 441 _ <br />Private Water Supply' Identify the source (well. spring. surlaCe. etc.) <br />Private Water Supply: Initial Water Quality Results <br />C.:nett< Poxes below if initial water testing nas been completee <br />All testing must be done at a State Certified Laboratory. Eitner attach lab results a• provide name of lab, date <br />results in space provided next to type of test <br />'iTestinq frequency for transient Non-Community Water Systems after initial testing! <br />o bacteriological Test (quarterly): <br />O N.'rate lest (yearly') <br />O Ni:rite lest (every 3 years"): <br />:•Asoit,onai information may be requlee if food ,rs prepared from a hen* Wel A private water supply - chock rept local jorescect,on <br />ti. Food Processor Course: Initial if you agree VI abide by the following: <br />Within 3 months of being apptoved to operate by tne Emironmental Health Department. please provide pi:x-2' <br />of completion of the California Food Handler course in lieu of the California Department of Public Health <br />1CDPH) food processor course. <br />;n - more rformatal sett CDPH webSal WWW,Oliph,C44.90VirClaraltle/Pignitditorrialingt9SAIMil <br />4 ,- •t:427 "42e. a 7 rzeGpEroicTT:p:n c c,nc.•