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SA N A M U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit fl: 12345 <br /> Issued to county Cottlty saw <br /> Chocolate Chip Cookies With Wahwts w <br /> f ti Sally Baker <br /> 123 Cottage Food Lwe a <br /> 4: A"whene,CA 90.3M <br /> hW*&eats: Emiched flora(Wheat flour,niaca redaoed;raQt <br /> mononitrate,riboflavin and folic acid),butter(unk sah),chocolate chips <br /> (sugar,chocolate liquor.cocoa baiter,butterfat(milk) waluuts sugar.eggs ,S <br /> salk artificial vanilla extract,baking soda. t <br /> Contains:Wheat,eggs,MRk.soy,waluats <br /> Net wt.3 oz(85.0490 <br /> Note:For the'Issued in county"-Identify the junsdlotion(citylcounty)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> 0Public 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: Ci Rnc <br /> ❑ Private Water Supply—, Identify the source (well, spring, surface, etc.): <br /> Private Wafter 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 ww—w.cdph.ca.gov/prOurams/PagestfdbCottaneFoocLaspx <br /> EHD 16-27 6/29/17 4 of 5 <br /> CFO REGIPERMrrr1NG FORM <br />