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SAN J O A Q U I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN' <br /> Permit M 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90= <br /> Ingredients: Enricher)flour(Wheat hoar,niacin,reduced iron,tluannue, <br /> mononitrate,riboflavin and folic acid),butter(hulk,salt).chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk). walnuts,sugar,eggs. <br /> salt,artificial vanilla extract,baling soda. <br /> Contalns:R'heat,eggs,milk,soy,walnuts <br /> Net Wt.3 oz.(85.049g) <br /> Note:For the'Issued in County"-Identify the jurisdiction(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 /> 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 heck aaw�e box) <br /> ame of Public Water System or Community Services District: AOUA VKV1 gousp_ comm-knG sevilCA- <br /> 1 <br /> - <br /> 9 is1 vtc <br /> El 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(every3 years*): <br /> **Additional information may be required if food Is prepared from a home with a private water supply—check with local jurisdiction. n <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.cdi)h.ca.aoviprocirams/Pages/fdbCottageFood.aspx <br /> 4 of 5 <br /> EHD 16-276/29/17 CFO REGIPERMnTING FORM <br />