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Example: <br />MADE 1n A HOAR KITCHEN <br />PermL #: 12345 <br />Issued in Cori County nave <br />Chocolate Chip Cookies R ith Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />An3whe e, CA 901a.0 <br />Ingredients: Enriched floor (Wheat non. uiacm reduced uou. thiamine, <br />mononitrate, riboflavin and folic acid), better (milk. salt), chocolate chips <br />(sugar, chocolate liquorcocoa lamer, butterfat (milk), uralmns, sugar, eggs, <br />salt, artificial vanilla extram toll* soda. <br />Contalw Rl=t, eggs, milk. soy, vminuis <br />Net WL 3 cm (85.0498) <br />lt(E For the 'Issued In County' - Identity 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 />qKJ 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 />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />Name of Public Water System or Community Services District: MouflM'1)oo� (,am p (� kr vi <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 home with a private water supply — check with local jurisdiction.. <br />8. Food Processor Course: Initial if you agree to abide 4y the following: 14 ' <br />Q <br />Within 3 months of being approved to operate by the Environmental Health Department, please <br />proviTe—p-ro—oT-oT completion of the California Food Handler course in lieu of the California Department <br />of Public Health (CDPH) food processor course. <br />For more information see CDPH website www.cdoh.ca.aovioroarams/PanesMbCotfaneFood.asox <br />EHD 16.27 6/29/2015 4 CFO REG/PERMrrnNG FORM <br />