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SANJ O A Q U I N Environmental Health Department <br /> COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit p: 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\.KX <br /> Ingredients: Enriched flour(Wheal flour,nincin,reduced icon,thiamine, <br /> mononilnte,riboflavin and folic acid),butler(milk.sall),chocolate clips <br /> (sugar.chocolate liquor,cocoa butter,butterfat(milk), walnuts.sugar,eggs, <br /> salt,artificial vanilla exinct,baking soda. <br /> Contains:Nlient,eggs,n llkq soy,nations <br /> Net\\'t.3 o2.(85.049g) <br /> Note:Forthe"Issued In County"-Identify the Jurisdiction(citykounty)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 /> VName of Public Water System or Community Services District: City Of Tracy <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 Wth a private water supply—check with local Jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: (3 <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.ca.aoviprogramslPares/fdbColtaoeFood.aspx <br /> 4 of <br /> EHD 16-276/29/17 CFO REG/PERMITTING FORM <br />