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SANJ O A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> 'NL-t.DE IN A 100E I ITC 14EN <br /> Permit=: 12345 <br /> Issued in count-: Count).name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 12"Cottage Food Lane <br /> Anywhere.CA 90X= <br /> Ingredients: Enriched flour(Wheat flour,niacin.reduced iron.thiamine. <br /> mononitrate.ribotlavin and folic acid).butter(milk,salt).chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk), wahnus,su«ar.eerys. <br /> salt.atiiticial vanilla extract.baking soda. <br /> Contains:Wheat,eggs,milk,soy,Nvahtuts <br /> Net NVI.3 oz.(8,5.049g) <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 /> Name of Public Water System or Community Services District: <br /> ❑ Private Water Supply**, Identify the source (well, spring, surface, etc.): Y <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 /> Food Processor Course: <br /> 8 o d use. Initial if you agree to abide by the following: J� <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.cdpli.ca.gov/programs/Pages/fdbCottageFood.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />