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SANJ O A Q U I N Environmental Health Department <br /> ---COUNTY <br /> Example: <br /> MADE INA HOME KITCHEN <br /> Permit p: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sall•Baker <br /> 12?Cottage Food Lane <br /> Aln- here.CA 90XXX <br /> Ingredients: Enriched flour(Wheat flour.niacin.reduced iron.thiamne. <br /> inououivate.nbotlavin and folic acid).butter(milk.salt).chocolate drips <br /> (sugar.chocolate liquor.cocoa butter.butterfat i milk). nahutts.sugar,egg,. <br /> salt.artificial vanilla extract.baking soda. <br /> Contains:Wheat,eaggs,milk,soy,walnuts <br /> Net Wt.3 oz.(35.049(g) <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: JJ <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) 61 5-, <br /> Name of Public Water System or Community Services District: LybyA t C � <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 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.gov/programs/Pages/fdbCottaneFood.aspx <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />