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SAN10 A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> NLADE IN A H01NIE KITCHEN <br /> Peru-tit#: 12315 <br /> Issued in county: County name <br /> Chocolate Clip Cookies With Waluuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere.CA 90.VO1 <br /> Ingredients: Enriched flour(Iklreat floiu,niacin,reduced iron,thiamine, <br /> mononitrate,riboflavin and folic acid),butter(milk.salt).chocolate chips <br /> (sugar,chocolate liquor.cocoa butter,butterfat(null:), walnuts,sugar.eg.s. <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:RLeat,eggs,mill:,sop,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 County Environmental Health Department <br /> immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> 'RName of Public Water System or Community Services District: Cd WOE <br /> ❑ Private Water Supply**, Identify the source (well, spring, surface, etc.).- <br /> Private <br /> tc.):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 jurisdicti n. <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 provide proof <br /> of completion of the California Food Handler course in lieu of the California Department of Public Health <br /> (CDPH) food processor course. <br /> For more information see CDPH website www.cdph.ca.qov/programs/Pages/fdbCottageFood.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />