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Example: <br /> MADE IN A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued in county: County name <br /> Chocolate Clup Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere.CA 9 VCX <br /> Ingredients: Enriched flour(Arheat flour,niacin.reduced iron.thiamine. <br /> mononitrate.riboflavin and folic acid),butter(nulk,salt).chocolate chips <br /> (sugar.chocolate liquor.cocoa batter..butterfat(rrink), walnuts,sugar.eggs, <br /> salt.artificial vanilla extract,baking soda. <br /> Contains:Ni heat eggs,milk 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 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: c 1.1...1 qF � A aM�i� <br /> El Private Water Supply**, Identify the source (well, spring, surface, etc..):I 1`� <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: cNJ <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.edph.ca.cioviprograms/Paues/fdbCotLageFood.aspx <br /> EHD 16-27 6/29/2015 4 CFO REG/PERMITTING FORM <br />