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Example: <br /> MADE INA HOME KITCHEN <br /> Permit#: 12345 <br /> Issued in county: Couny name <br /> Chocolate Chip Coolies With Walnuts <br /> Sally Baker <br /> 123 Cottaee Food Lane <br /> Anywhere,CA 90.1'1."4 <br /> Ingredients: Enriched flour(Wheat flow,intent.reduced iron.t a aurin, <br /> nmuoninate.riboflavin and folic acid).butter(null:,salt).chocolate chips <br /> (sugar,chocolate liquor.cocoa butter,bnderfat(nulk). walnuts,sugar.eggs. <br /> salt,artificial vanilla extract,baking soda- <br /> Contains:wheat,eggs,mill:,soy,walnuts <br /> Net Wt.3 oz.(85.0498) <br /> Please check what type of treatment is used to dispose of waste <br /> rLIN <br /> Ol 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 /> [Q Name of Public Water System or Community Services District: C I i 0 f Lo d <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 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.cdoh.ca.gov/orograms/PaaesifdbCottaaeFood.asux <br /> EHD 16-27 7/27/17 4 CFO REG/PERMITTING FORM <br />