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17-Nov-2028 16:25 Private And Confidential. From:2093679996 p.4 <br /> SAN.,,,,,J <br /> i 3\A Q 11 IN <br /> Environmental Health Department <br /> C.C)li <br /> ) 11TY .._..... <br /> Example: <br /> MADE IN A HO\{E KITCHEN <br /> Permit fl: 12345 <br /> Issued bt mmrty: County uaure <br /> Chocolate Chip Cookies With Walnuts <br /> sally Baker <br /> 123 Collage Food Lave <br /> An)Mhoe,CA 90XXX <br /> fngredlenIs: Ltuirbed goer(Whew hoar,niacin,reduced iron,thiamine. <br /> monoui(mte,ribollavin and folic acid).huller Onilk;sill).dlocoliteehips <br /> (sugar,chocolate liqumv,cocoa batter,bumeda(milk), tsmlauls,sugar,eggs, <br /> sail,nnificiol vanilla eurnct,baking soda. <br /> Contains:Wheat,eggs,milk,soy,uninuls <br /> NetR9.3 oz(85.049g) <br /> Note:For the'Issued in Counly"-Identify the furisolcrion(cky/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Ptease 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 Idenli6,the water source to be used in Cottage Food FaclIV(check one box) <br /> ❑ Name of Public Water System or Community Services District: <br /> Private Water Supply", Identify the source (well,spring, surface, etc.): <br /> L <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,dale& <br /> results in space provided next to type of test. <br /> *(Testing frequency for transient Non-Community Water Systems after initial testing)' <br /> i�Bacteriological Test(quarterly`): *4f L <br /> ,Nitrate Test(yearly'): 3 k. <br /> ,Nitrite Test(every 3 years*): <br /> "Additional information may be required if food is prepared from a home Ydth a private waler supply—check with local jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: __za_l <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 cdoh caaovtoroorams(PaaeslfdbCbttaagEood asox <br /> 4 of <br /> EHD 10-27 0120117 CFO REGIPERM13T W G FORM <br /> Received Time Nov, 11. 2020 3 : 19PM No. 6468 <br />