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Example: <br /> \LADE In A HOME KITCHEN' <br /> Permit fi: 12335 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baler <br /> 123 Cottage Food Lure <br /> Anywhere,CA 903M <br /> Ingredients: Enriched flour(Wheat flow,niacin.reduced iron.thiamine. <br /> nrououitrate,riboflavin and folic acid).butter(milt:.salt),chocolate chips <br /> (sugar.chocolate liquor,cocoa butter.butterfat(milk), walnuts,sugar,eggs. <br /> salt.arlificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,mWc,soy,walnuts <br /> Net Wt.3 oz.(85.049g) <br /> Note:For the"Issued in County%Identify 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 /> Public Sewer Service ❑ Private Septic System <br /> In the event of septic system failure or plumbing problem,you are required to notify San Joaquin Courtly 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: i I f l l IOM <br /> El Private Water Supply`*, Identify the source (well, spring, surface, etc.): aI <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 /> B. Food Processor Course: Initial if you agree to abide by the following: <br /> Within 3 months of being approved to operate by the Environmental Health Department, please <br /> provide proof of 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.cdz)h.ca.goviprograms/PaaesMdbCottageFood.ast)x <br /> EHD 16-27 6/29/2015 4 CFO REGIPERMIrTING FORM <br />