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Example: <br /> BIG CAKE BAKER <br /> stcckton CA g5_C9 <br /> Perm't#GIZB45 <br /> issued in: San Joaquin Count,; <br /> Chocolate Chip Cookies with Walnuts <br /> Ir.-redierts:Errichedilcur Ir',heatilcur,rlacir,reduced iron,thiamine,mcnonitrete,riWI3,ir <br /> and fctic acid i,cutter Irrilk,saltj,theccdate cFiEs tsu,=_r,chocctateliquar,retca tutter,turterfat <br /> I lmiik?,V:atrut_,su;ar,eggs,salt,artifirialvarllla wttaz:,ttaijrs;cda <br /> i <br /> Contains: Wheat, milk, eggs, soy, walnuts <br /> i <br /> Made in a home kitchen <br /> Net Wt. 3 oz. (85.133g) <br /> i <br /> N91a;For the"Issued in County"-ldenidy 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 /> X 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 <br /> Department immediately. <br /> 7. Water Source: <br /> Please Identify the water source to be used in Collage Food Facility(check one box) <br /> X Name of Public Water System or Community Services District: City of Lathrop, Utilities Services <br /> ❑ Private Water Supply—, Identify the source (well, spring, surface, etc.): <br /> Private Water Supply: initial Water Quality Results <br /> Check boxes below it 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 /> EHD 16-27 6129/2623 4 CFO REGIPERMITTING FORM <br />