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Example of label: <br />EHDMWiaaaa CFO R£GA>ERMITnNG FORM5 <br />209OaKEBfiKff} <br />Stockton CAZIP CODE <br />PR#0000000 <br />Issued in: San Joaquin County <br />ChoodateCHp Qxkies with V^nuts <br />rtaC'n‘ lron' th*am'r*. mononitrate, riboflavin, and folk acid), butter (mXk, sat), <br />P® ( 0a , chocolate Bquor, cocoa butter, butterfat (milk), walnuts, sugar, eggs. salt, artificial vanffla extract, baking soda <br />Contains: Wheat, milk, eggs, soy, walnuts <br />Made in a Home Kitchen <br />Net Wt. 3 oz (85.05g) <br />7, Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />■ Name of Public Mfeter System or Community Services District: City of Lodi Public Water Utility <br />□ Private Water Supply**, Identify the source (well, spring, surface, etc.): - ------------— <br />Private Water Supply: Initial Water Quality Resulta ----------------------------------------- <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 /> <br />□ Nitrate Test (yearly*): ' <br />□ Nitrite Test (every 3 years*): ' <br />“Addttonal tnfomwtion may be required f food to prepared from a home w«h a private water supply - check wdh focal jurtedkbon. <br />tJota. For the "Issued In County" - Identify the Jurisdiction (dty/county) when you en obtaining approval <br />6, Disposal of Wgsfe: <br />Please check what type of treatment is used to dispose of waste <br />| Public Sewer Service D private Septic System <br />D^rSXt knmSdtateyy°U ‘0 S*n Joaqu,n CoUnty Envl«»nm«nta» Health