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SA N J O A Q U i N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> NLADE IN A HOME IQTCHEX <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Coolaes With Walnuts <br /> Sall,Saker <br /> 123 Cottage Food Lane <br /> Auswhere.CA 901LX-C <br /> Ingmilenty &melted floor(Wheat flow.niacim reduced iron.thiamine. <br /> mononitrate.riboflavin and folic acid),butter(n i1L- salt).chocolate clips <br /> (sugar.chocolate lkluor,cocoa butter,butterfat(milk). lvahntis,sugar.egos. <br /> salt.artificial squilla extract,baking soda. <br /> Contains:Nhest,eggs,milk,soy,walnuts <br /> Net R9.3 oz(85.049g) <br /> Note:For the-issued in County"-Identify the jurisdiction(raty/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: M00t.PMi k ){v(JS GS b <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. 6U—ZVSArPE CeZTIFt (A-tE 5630 &JCP <br /> For more information see CDPH website www.cdph.ca.oov/oroamms/PanesMdbCottaaeFood.mox <br /> EHD 1627 6/29/17 CFO REG/PERMITTING FORM <br />