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SAN10 A Q U I N Environmental Health Department <br /> COUNTY— <br /> Example: <br /> OUNTYExample: <br /> MADE IT A HOME ICITCHEN <br /> Permit#: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Coolies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lave <br /> Anylvhem CA 90�'t <br /> Ingredients: Enriched flour('Aleat flour,niacin,reduced iron,thiau»ne. <br /> monovibate.nboMvm and folic acid),butter(milk,salt),chocolate clips <br /> (sugar,chocolate liquor,cocoa butter.butterfat(milk), walnuts,sugar.eggs. <br /> salt.artificial vanilla extract,baking soda. <br /> Contains:RLeat,eggs,milk,sop,walnuts <br /> Net Wt.3 oz(85.0498) <br /> Note:For the"Issued in County".Identify the jurisdiction(city/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 Hea@h Department <br /> Immediately. <br /> 7. Water Source: <br /> P ase Identify the water source to be used in Cottage Food Facility(check one box) <br /> Name of Public Water System or Community Services District: CN IFoRt�t W a c�R SP)U.kE <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, plea 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.gov/programs/PaueslfdbCottageFood.asox <br /> 4 of <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />